Witness appearing before the House Subcommittee on Labor-HHS-Education Appropriations (April 28, 2010)
Josephine P. Briggs, M.D., Director
National Center for Complementary and Alternative Medicine
Mr. Chairman and Members of the Committee:
I am pleased to present the President's Fiscal Year (FY) 2011 Budget request for the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. The FY 2011 budget includes $132,004,000, which is $3,213,000 more than the comparable FY 2010 appropriation of $128,791,000.
The National Center for Complementary and Alternative Medicine is entering its second decade as the Federal Government's lead agency for research on complementary and alternative medicine (CAM). NCCAM's mission is to explore CAM healing practices in the context of rigorous science, train CAM researchers, and disseminate authoritative information to the public, health care professionals, and policy makers. In the past 10 years, NCCAM has funded more than 2,500 research projects resulting in more than 3,300 scientific articles in peer-reviewed journals. This work has increased the knowledge base of the effects, efficacy, safety, and promise of many CAM interventions.
CAM is a group of diverse medical and health care systems, practices, and products, such as herbal supplements, meditation, chiropractic, and acupuncture that are not generally considered to be part of conventional medicine. The most current and comprehensive picture of Americans' use of CAM was developed under NCCAM leadership through the 2002 and 2007 National Health Interview Surveys (NHIS). The surveys found that nearly 40 percent of adults use some form of CAM. NHIS data also show that Americans spend $33.9 billion out-of-pocket on CAM, accounting for approximately 1.5 percent of total health care expenditures and 11.2 percent of total out-of-pocket expenditures on health care. As these data show, CAM use is significant, both in the number of people using CAM, and in the out-of-pocket costs they are willing to pay for CAM products and services.
Understanding and Treating Pain
Given both patterns of use and scientific promise, research on CAM for chronic pain is a top priority for NCCAM. Millions of Americans suffer from chronic pain. Its annual economic cost, including health care expenses, lost income, and lost productivity, is estimated to be $100 billion. Chronic pain is by far the most common reason Americans use CAM. NCCAM-funded studies indicate that certain CAM therapies (e.g., relaxation techniques, acupuncture, chiropractic manipulation, and massage) show promise for the management of chronic pain. Such evidence is contributing to the adoption of CAM practices in clinical practice guidelines. For example, recommendations from the American Pain Society and the American College of Physicians include acupuncture, massage therapy, spinal manipulation, and yoga as options in managing chronic low back pain.
NCCAM-funded basic and clinical research in pain management has demonstrated promising results in a number of areas. Basic research has provided evidence of effects of some mind-body practices on the underlying biological mechanisms of pain perception. For example, brain imaging studies have yielded insights into such central mechanisms activated by placebo analgesia and acupuncture. Clinical studies have shown that patients with chronic low-back pain who received acupuncture or simulated acupuncture treatments benefited more than patients receiving only conventional care. Ongoing research is also comparing the cost and utilization of conventional medical services for the treatments of musculoskeletal pain conditions by patients who use CAM providers with those who do not.
NCCAM is strengthening its research portfolio on nonpharmacological methods for the prevention, reduction, or amelioration of pain. To that end, NCCAM recently refined its signature research program, Centers of Excellence for Research on CAM (CERC), to focus on studying CAM therapies for pain management. Through the CERC initiative, investigators at leading research institutions will develop multidisciplinary, synergistic research programs to investigate the potential of promising nonpharmacological CAM approaches for the treatment of pain.
NCCAM is also investing resources in back pain research. Back pain is the leading cause of work-related disability and missed days of work and the fifth-most-common reason for physician visits. Back pain results in significant health care costs to individuals, insurers, and society overall. Unfortunately, treatment strategies currently available for back pain are only partially effective. According to the 2007 NHIS survey on CAM use, back pain is the most common condition for which adults use CAM. They incorporate CAM into their care with the hope of decreasing pain, improving function and quality-of-life, preventing recurrence and chronicity of pain, and/or avoiding the side effects of conventional treatments for back pain.
NCCAM is leading an effort at NIH to assess the current state of the science of back pain and to identify the most important research questions aimed at developing better pain management strategies. In 2009, NCCAM, in collaboration with several other NIH Institutes and Centers, hosted the NIH Workshop on Nonpharmacologic Management of Back Pain. The main conclusion of this workshop was that there is an urgent need to better understand the causes and mechanisms of back pain. This topic will be explored further in May of this year at a second trans-NIH workshop that will bring together experts with diverse expertise to discuss back pain. Participants in the workshop will identify gaps in the NIH research portfolio on back pain and research opportunities. The workshop also will include a discussion of how promising CAM approaches may be used for the management of back pain.
Many people use natural products such as fish oil, glucosamine, and Echinacea and other botanicals for the treatment of a variety of conditions and/or to improve or maintain their general health. NCCAM's research has substantially contributed to the understanding of both the safety and the efficacy of natural products. Furthermore, NCCAM's research has contributed to greater public awareness of how to use dietary supplements wisely. For example, recent data from both NHIS and industry surveys suggest that the findings from NIH-funded research on the safety and efficacy of the supplements Echinacea, vitamin E, and fish oil (omega-3 fatty acids) has influenced the public's use of these supplements.
NCCAM is committed to building a base of rigorous, objective, and scientific evidence on the safety and efficacy of natural products. Understanding the biological effects and mechanisms of action of natural products used as CAM interventions is a crucial step toward designing rigorous, informative interventional trials of these products. For many natural products, such data are not currently available. And in light of reports highlighting safety concerns of natural products, the Center, in close cooperation with regulatory agencies, will maintain its focus on helping to provide consumers, health care providers, and policymakers with reliable, objective data regarding the safety of natural products to fill these knowledge gaps.
NCCAM-funded natural product researchers are taking advantage of the unprecedented scientific opportunities now available to understand the mechanisms by which natural products could change disease processes through the application of state-of-the-art technologies, such as high throughput screening methods, studies of epigenomics, and studies of the microbiome. These techniques hold great promise in elucidating and clarifying insights into the biological mechanisms of complex natural products, and perhaps in identifying promising leads for new therapies from them.
Looking Ahead To the Next Decade
NCCAM has embarked on a comprehensive strategic planning process that will ensure that the Center continues to support the best and most promising CAM research. In prioritizing which studies to undertake, four factors come into play: (1) Promise: Is there evidence that the research may lead to the development of improved strategies for treating troublesome or prevalent health conditions (e.g., chronic pain)? (2) Science: Is the project amenable to rigorous scientific investigation given available methods, tools, and technologies? (3) Impact: Is there a reasonable likelihood that the research may influence CAM practice(s) by consumers and/or health care providers, thus ultimately impacting public health? and (4) Use: Is the CAM intervention widely used?
Under NCCAM's leadership, CAM research is evolving and the body of evidence of what works and what does not, what shows promise and what has safety concerns, and what the public and health care providers want and need to know is also changing. Through multiple channels such as the NCCAM web site, the information clearinghouse, continuing medical education, and publication databases, the Center brings evidence-based information to the public and health care providers. As CAM becomes more integrated into health care, the need for patients and providers to talk openly about CAM use grows. NCCAM's “Time to Talk” educational campaign continues to encourage this important dialogue to help ensure safe, coordinated care. Through these and other activities, NCCAM will fulfill its obligation to the American public and health care providers to determine how, when, and under what circumstances CAM works.
Department of Health and Human Services
National Institutes of Health
National Center for Complementary and Alternative Medicine
Josephine P. Briggs, M.D.
Dr. Briggs is Director of the National Center for Complementary and Alternative Medicine (NCCAM). She received her A.B. cum laude in biology from Harvard-Radcliffe College and her M.D. from Harvard Medical School. She was a professor of internal medicine and physiology at the University of Michigan from 1993 to 1997. From 1997 to 2006 she was director of the Division of Kidney, Urologic, and Hematologic Diseases in the National Institute of Diabetes and Digestive and Kidney Diseases. From 200–2007, she was senior scientific officer at the Howard Hughes Medical Institute. She was appointed NCCAM's Director in January 2008.
Dr. Briggs has published more than 125 research articles and is on the editorial boards of numerous journals. She is an elected member of the American Association of Physicians and a fellow of the American Association for the Advancement of Science. She is also a recipient of the Volhard Prize of the German Nephrological Society. Her research interests include the renin-angiotensin system, diabetic nephropathy, and the effect of antioxidants in kidney disease.