Witness appearing before the Senate Subcommittee on Labor-HHS-Education Appropriations
May 21, 2009
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 2010 Budget request for the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. The FY 2010 budget includes $127,241,000, which is $1,770,000 more than the comparable FY 2009 appropriation of $125,471,000.
In December 2008, the National Center for Complementary and Alternative Medicine (NCCAM), in conjunction with the National Center for Health Statistics, released data from the 2007 National Health Interview Survey (NHIS)1. The survey is the most comprehensive and reliable information to date on the use of complementary and alternative medicine (CAM) in the United States. The 2007 NHIS data confirm that millions of Americans—38 percent of U.S. adults and 1 in 9 children—use CAM to promote health and wellness and to address specific conditions such as chronic pain.
The NHIS data affirm the public health importance of NCCAM's mission to develop an evidence base for the integration of CAM with conventional health care and to disseminate research results to the public and health care professionals. Since its founding 10 years ago, NCCAM has created a nationwide CAM research enterprise, built on sound scientific principles, that enables the rigorous study of CAM. Among NCCAM's accomplishments are a Centers of Excellence program at leading biomedical research institutions; standards for quality and stability for the natural products used in research; and the development of tools and methodologies to discover the potential benefits and risks of CAM modalities. Today, under NCCAM's leadership, partnerships between biomedical research institutions and CAM institutions and practitioners are engaged in state-of-the-art scientific research. NCCAM-supported CAM research has resulted in over 3,300 peer-reviewed publications. Professional associations, such as the American College of Physicians and the American Academy of Orthopedic Surgeons are now able to use CAM research findings to inform their practice guidelines. NCCAM will continue to meet the challenges of building the evidence base for CAM interventions through its rigorous research, research training, and outreach endeavors. NCCAM's budget request and its research projects are consistent with the President's multi-year commitment for Cancer and Autism.
1. Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 10, 2008
A Structured Approach to Answering Key Questions
CAM research is a promising scientific endeavor that requires multidisciplinary basic, translational, and clinical trial collaborations. In FY 2010, NCCAM will fund awards under a new initiative, Partnerships for Complementary and Alternative Medicine Clinical Translational Research. This initiative, which replaces the NCCAM Developmental Centers for Research on CAM program, will foster such collaborations at CAM institutions and create tools and methodologies for research.
NCCAM investigations span the continuum of research areas: basic (how does the therapy affect the body?); translational (do we have the methods and tools to detect and measure the modality's effects?); efficacy (is there evidence of safety and benefit under optimal research conditions?); and effectiveness (how well does the CAM practice work in the “real world” and in comparison to other treatments?). NCCAM has strong programs in all four of these areas; its current research strategy places particular emphasis on strengthening effectiveness research.
Area of Promise and Investment: Managing Chronic Pain
The 2007 NHIS data indicate that chronic pain is, by far, the most common health problem for which Americans turn to CAM. NCCAM-supported basic, translational, and clinical research is using state-of-the-art neuroscience, brain imaging, and novel study designs to demonstrate that mind-body medicine approaches, such as massage, chiropractic, and acupuncture, affect pain perception and to understand how patient expectancy and practitioner reassurance may have an impact on pain management. For example, using functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), basic researchers are developing important insights into how acupuncture affects specific pain networks in the brain. In addition, emerging data, such as the recent report in the Annals of Internal Medicine that massage therapy and simple touch may provide pain relief for advanced cancer patients, point to the promise of mind-body practices. NCCAM is focusing on developing the evidence base for the use of non-pharmacologic CAM practices for pain management.
Chronic back pain is a problem for millions of Americans, and costs associated with it total at least $50 billion annually2. It is often difficult to treat, and medications used to address it can have troubling side effects. Certain CAM therapies, such as acupuncture, chiropractic, massage, and yoga, show promise in treating chronic back pain. In May 2009, NCCAM is sponsoring, with other NIH Institutes and Centers, a workshop on non-pharmacologic interventions for the treatment of chronic back pain, bringing together experts to identify gaps in the CAM evidence base and opportunities for future research. NCCAM plans to fund awards in FY 2010 under a new initiative, Effectiveness Research—CAM Interventions and Chronic Back Pain. This initiative will support studies of CAM approaches to address a range of outcomes for back pain, such as reduced dependency on narcotics.
2. Low Back Pain Fact Sheet; National Institute of Neurological Disorders and Stroke, National Institutes of Health, Department of Health and Human Services, July 2003.
Area of Promise and Investment: Translational Tools
Basic and translational (i.e., “bench-to-bedside”) research is especially challenging for CAM mind-body practices, acupuncture, and body-based and manipulative therapies, because current scientific methods may not adequately capture and measure the effects of these therapies. To decipher these practices' potential physiological effects and enable scientists to study them in clinical trials, better scientific tools, metrics, and methodologies must be developed. In FY 2010, NCCAM will fund awards under its initiative, Program for Translational Tools for CAM Clinical Research. The research supported under this initiative will improve the quality and reproducibility of CAM clinical investigations.
Area of Promise and Investment: Natural Products
According to the 2007 NHIS, almost 40 million U.S. adults and 2.850 million children use natural products to manage their health and wellness. Given the widespread use of dietary supplements, NCCAM's research into the safety and efficacy of natural products remains a public health priority.
NCCAM-supported studies, including collaborations under the NIH Botanical Research Centers program, demonstrate the promise of natural products research. For natural products, basic and translational research remains critical precursors to large-scale clinical trials. A recent study by the University of Maryland and Rutgers University elucidated an immune system mechanism of action of green tea polyphenols on rheumatoid arthritis. In another study, Duke University researchers reported that bromelain, an enzyme derived from pineapple stems, reduced inflammation resulting from Crohn's disease and ulcerative colitis.
Although natural products research shows great promise, product quality remains a significant issue. In July 2008, an NCCAM-funded study in the Journal of the American Medical Association reported that one-fifth of Internet-available Ayurvedic medicines contained detectable levels of lead, mercury, and arsenic. The authors also found evidence for benefit of industry-established standards for quality in reducing levels of toxic metals. NCCAM has led the scientific community in requiring that all natural products used in its research undergo quality and stability screening to ensure that the research is safe and reproducible. Ongoing collaborations with the dietary supplement industry are important to this effort. Equally important are NIH partnerships in the development of an evidence base for natural products.
Making Wise Decisions: Outreach
Studies confirm that consumers do not tell their doctors that they use CAM, and doctors do not ask their patients about CAM use. To ensure safe, coordinated care NCCAM developed its Time to Talk patient and provider education program. NCCAM also partnered with the National Institute on Aging to develop a CAM section on NIH Senior Health, the NIH website especially for older adults.
In FY 2009, NCCAM will initiate a new educational section of its website (nccam.nih.gov) to provide health professionals with evidence-based information and clinical practice guidelines on CAM use. NCCAM also cosponsored the North American Research Conference on Complementary and Integrative Medicine, on May 12–15, 2009. This international meeting of scientists and CAM and conventional practitioners highlighted the emerging science on CAM and future directions for research.
NCCAM: Looking to the Future
There are areas of considerable promise and potential for the field of CAM research, and NCCAM will focus its resources to ensure that they will be optimally directed. The Center has begun to develop its next strategic plan, seeking the input of the scientific community as well as its diverse community of stakeholders. As a first step in this process, the Center has convened a Blue Ribbon Panel to consider future directions for its intramural research program.
Thank you for the opportunity to testify. I would be pleased to answer the Committee's questions.
Josephine P. Briggs, M.D. Director, NCCAM
On January 24, 2008, Josephine P. Briggs, M.D., was named Director of the National Center for Complementary and Alternative Medicine. An accomplished researcher and physician, Dr. Briggs brings a focus on translational research to the study of complementary and alternative medicine to help build a fuller understanding of the usefulness and safety of CAM practices.
Dr. Briggs received her A.B. cum laude in biology from Harvard-Radcliffe College and her M.D. from Harvard Medical School. She completed her residency training in internal medicine and nephrology at the Mount Sinai School of Medicine, New York, NY, where she was also chief resident in the Department of Internal Medicine and a fellow in clinical nephrology. She then held a research fellowship in physiology at Yale School of Medicine, New Haven, CT, working with Dr. Fred Wright and Dr. Gerhard Giebisch. After completing her fellowship at Yale, Dr. Briggs was a research scientist for 7 years at the Physiology Institute at the University of Munich, Munich, Germany.
In 1985, Dr. Briggs moved to the University of Michigan, Ann Arbor, MI, where she held several academic positions, including associate chair for research in the Department of Internal Medicine and professorships in the Division of Nephrology, Department of Internal Medicine and the Department of Physiology. Dr. Briggs joined the National Institutes of Health in 1997 as director of the Division of Kidney, Urologic, and Hematologic Diseases at the National Institute of Diabetes and Digestive and Kidney Diseases where she oversaw extramural research activities. While at NIDDK, she co-chaired an NIH Roadmap Committee on Translational Core Resources. In 2006, she accepted a position as senior scientific officer at the Howard Hughes Medical Institute.
Dr. Briggs' research interests include the renin-angiotensin system, diabetic nephropathy, circadian regulation of blood pressure, and the effect of antioxidants in kidney disease. She has published more than 130 research articles and has served on the editorial boards of several journals including the Journal of Laboratory and Clinical Medicine, Seminars in Nephrology, and Hypertension and was deputy editor for the Journal of Clinical Investigation. She is an elected member of the American Association of Physicians and the American Society of Clinical Investigation and a fellow of the American Association for the Advancement of Science. She is a recipient of many awards and prizes, including the Volhard Prize of the German Nephrological Society, the Alexander von Humboldt Scientific Exchange Award, and NIH Director's Awards for her role in the development of the Trans-NIH Type I Diabetes Strategic Plan and her leadership of the Trans-NIH Zebrafish committee.