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N C C A M Research Blog

“Integrative”—What Is in a Word?

May 24, 2012
Dr. Briggs
Josephine P. Briggs, M.D.

Director
National Center for Complementary and Alternative Medicine

View Dr. Briggs's biographical sketch

Having just returned from the 2012 International Research Congress on Integrative Medicine and Health, the term “integrative” and its various meanings are very much on my mind.

The legislation that created NCCAM puts a clear emphasis on integration. Here is what the law says:

The Director of the Center shall, as appropriate, study the integration of alternative treatment, diagnostic and prevention systems, modalities and disciplines with the practice of conventional medicine as a complement to such medicine and into health care delivery systems in the United States.

S.2420, July 31, 1998

That seems simple enough but there are a lot of rough edges at the interface between conventional medicine on the one hand and use of complementary/alternative health approaches on the other, and “integrative” can get caught in a highly polarized debate. From one end, “integrative medicine” offers a holistic, gentle, patient-centered approach that will solve many our Nation’s most pressing health care problems. At another end, “integrative care” represents an evasive rebranding of modern equivalents of “snake oil” by practitioners who raise unrealistic hopes and promote approaches that are not sensible, supported by evidence, or proven safe.

So what does “integration” mean to NCCAM from our perspective at the NIH? We begin with three very well-documented facts:

  1. Individuals, their health care providers, and their health care systems are all, on a large scale, incorporating various practices which have origins outside of mainstream medicine into multi-pronged treatment and health promotion approaches.
  2. This “integrative” trend among providers and health care systems is growing. Driving factors include perceived benefit in health or well-being, emerging evidence in at least some cases that perceived benefits of integrative are real and/or meaningful (e.g., management of chronic pain), and marketing of “integrative care” by health care providers to consumers.
  3. With few exceptions, data to guide evidence-based decision making about safety and efficacy are at best preliminary.

That’s where NCCAM comes in. We are focusing our resources on building better evidence to clarify whether interventions that are already being widely integrated into the real world of health care and health care systems—and for which there exists a reasonable scientific case for investment of valuable resources—are safe and have efficacy. For example, we are deeply invested in clarifying the role of non-pharmacological approaches as components of pain management.

That is NCCAM’s evolving perspective on the word “integrative.” We think it is a very useful construct because it is simple, pragmatic, and focuses on major trends in twenty-first century health care.

I’m eager to see where this line of investigation takes us and hope you will join our conversation.

Comments

Comments are now closed for this post.

Thank you for the blog and reminding us of the language from the 1998 legislation that is so inclusive covering “treatment, diagnostic and prevention systems, modalities and disciplines”.

Great blog! An aspect of the science of integration should focus on helping patients and providers make informed individualized decisions about treatments when the evidence base for CAM and conventional medicine are not complete. It is also important to see whether the individualized and tailored approach will lead to more optimal adherence to whatever approach the person takes and ultimately results in better health outcomes.

This is great news!
As an acupuncturist who enjoys reading research studies, no doubt the eastern medical paradigm will be included, since there is much evidence supporting its theories and applications to be effective, AND it is so cost-effective in the long run.
As just one example, acupuncture’s ability to relieve knee pain (Cochrane Reviews) could be a first line of treatment before recommending surgery.

Thanks for your thoughts Dr. Briggs. We are very supportive of coming up with more robust definitions for Integrative Medicine and Integrative Medical Practitioners. Please let us know how our field can be involved in constructing and upholding these definitions as we move forward together in providing high quality patient-centered care.

Michael J. Jabbour, MS, LAc
President, AAAOM Board of Directors

Thank you, Dr. Briggs and also the Advisory Board for taking on these complicated issues and providing usable consumer/ practitioner information on the NCCAM website. When it comes down to really using complementary treatment in my own healthcare, I found that my physician, while interested, does not have the time or background to help me blend the two together. I am on my own figuring out how to maximize using both. I would love to see more “pros and cons” given by NCCAM for specific treatments…while we await the long term scientific studies. Ulimately, we as individuals (not our MD’s) decide how we want to take care of our bodies. Put the information that is available now (if only pros and cons or the history in another culture of a treatment) out there and let patients weigh the information themselves. I have yet to hear “I’m waiting for a double blind study before I try … to relieve my pain”.

Great respect for Dr. Briggs and thanks for make this paradigm clear. I am from Indonesia really appreciate you work and like very much your journal “Journal of Laboratory and Clinical Medicine, Seminars in Nephrology, and Hypertension”

dr.Linda

Thanks, NCCAM, for providing a forum for discussion. I see this as a great opportunity to correct 2 common misperceptions: one - that complementary and integrative approaches are only for those who can pay out of pocket and two - that public health is only for those who are economically-challenged. Our communities are deeply in need of dialogue on these topics.
Beth Sommers PhD, MPH, LAc - Co-Chair of the American Public Health Association’s specialty group on Alternative and Complementary Health Practices

Great to see NCCAM start to mix it up with the community. For an outstanding description of integrative medicine, practice and thinking that is available on a daily basis for real patients, I heartily recommend yesterday’s radio interview with Adam Perlman, director of Duke Integrative Health, with host Frank Stacio. The most lucid explanation of the current state of the field I have come across, with excellent questions by Stacio.

http://wunc.org/tsot/archive/SOT61812ABC.mp3/view

It’s great to see NCCAM putting up a blog like this to create a forum for discussion. This post, in particular, gives a very good opportunity to talk about terminology. It would be incredibly helpful, and speak well of NCCAM, if an effort were made to bring terminology more in line with reality. For example, the term “conventional medicine” should really be dispensed with. There is, in reality, only “medicine”. In other words, medicine includes those things which have been shown, with an abundance of quality evidence, to actually work. Anything else (e.g., the majority of CAM) is either not yet proven to work or proven not to work and should not yet be called “medicine”.

When it comes to “integrative”, it would be particularly helpful and beneficial to patients to make clear that when CAM proponents talk about “integrative medicine”, what they are really saying is that they wish to integrate the unproven or the disproven with medicine.

Todd, the integrative medicine docs and practitioners I know repeatedly say that their goal is to practice good medicine. No one in integrative medicine that I know wishes to integrate the “disproven” into anything. Far from it. What they do want is a research paradigm that takes into account the effective outcomes for any therapy even it its mechanisms are still to be determined, which applies to many CAM approaches. To me CAM appears to be evolving to describe a discrete set of therapies, procedures, substances that may or may not be used as part of integrative approaches. NCCAM is here in part to figure out if and where and how they fit. If you read Dr. Briggs post on the pain management conference, it helps describe the problem that many standard meds offer little relief — again researchers don’t know why, while integrative therapies have demonstrated better efficacy. This is being demonstrated weekly, unfortunately, in military use of IM approaches for pain.

There is a useful review of this blog entry by Dr. Briggs posted here: http://scienceblogs.com/insolence/2012/06/20/oh-goody-nccam-has-a-blog/

@Taylor Walsh

My point is that those things that are called “integrative medicine” are, more often than not, either unproven or disproven. Most physicians really do not have a very good understanding of CAM and take more of a shruggie approach, not realizing that much of it is, to be blunt, nonsense (e.g., reiki). Those things which are actually plausible, like herbs, fall under the real, science-based field known as pharmacognosy (i.e., looking to nature for medicinal compounds and chemicals). Where CAM misses the mark with things like herbs is that it tends to promote using the whole plant, which leads to varying potencies, adulteration with other active chemicals and an increased risk of adverse effects.

Doctors want to do what is best for their patients. Unfortunately, they may inadvertently promote modalities that have little or no basis in science, modalities which ultimately cause no objective improvement in the physical condition and serve to waste patients’ time and money. If you pay close attention, when studies are very well-designed and controlled, CAM benefits tend to be limited to subjective symptoms or self-limiting conditions.

It’s because of these misunderstandings that I think that the terminology should really be fixed, as I mentioned in my comment above. NCCAM could help with this, improving the terminology to make it clear that there is medicine, and then there is all the stuff that either has not been proven to work or has been disproven.

@Carol Braverman

“As just one example, acupuncture’s ability to relieve knee pain (Cochrane Reviews) could be a first line of treatment before recommending surgery.”

If I recall correctly, that Cochrane review found that real acupuncture outperformed sham acupuncture and doing nothing, but there were not enough data to show that it was better than other sham/placebo treatments or active treatments. They also included one study that used “electroacupuncture” (this should really just be called what it is, TENS, and drop the acupuncture part of it - tying into the whole problem with terminology) and a drug (diclofenac) for both treatment groups; this study also had the most positive results, probably because the drug was actually helping them. They concluded that more research was necessary due to the wide variation in results.

Thanks for the tip on the radio program in which Dr. Adam Perlman is interviewed about his position heading up the Duke Integrative Health Program. Excellent discussion and worth listening to!

@Todd W — I think it is fair to say that the concerns you express have receded substantially, now that literally hundreds of conventionally trained physicians have adopted integrative medicine - primarily as a “whole person” approach (that may or may not include some CAM) - that is preferred by many scores of thousands of patients. The American Academy of Pediatrics 3 years ago established a formal section on “Complementary and Integrative Medicine” to help docs respond to parents. Later this year the HRSA will fund an educational program that will add evidence-based integrative medicine (as defined by NCCAM) as part of the residency training for preventive and primary care physicians.

I think if you check out the radio interview with Dr. Perlam at Duke I mentioned above, you’ll get a much clearer read on the contemporary role of integrative medicine and approaches than I can come up with.

I’d like to hear how “integrative” care would apply to treatment for ACL surgery, for example, where the care is usually pretty invasive and gross ( http://www.aclsurgery.us/acl-surgery-videos/ ). What are the alternatives?

@Taylor Walsh

On the contrary. The concerns I express have not receded. When I see reiki courses being offered to nurses for CME credit at large, well-respected hospitals, I become somewhat concerned, to put it lightly. Medicine should be based on sound science, rather than appeals to popularity. And, unfortunately for CAM, the majority of it lacks a sound, scientific basis. This is why I very strongly object to it being called medicine, even with the qualifiers “integrative” or “complementary”.

As to treating the “whole person”, I agree that this is part of the physician’s job. It involves talking to the patient and treating them as a person, addressing their psychological needs as well as the physical. But that does not mean that physicians should clap onto magical thinking or pander to such in their patients. If a patient expresses interest in some modality that has no scientific basis or any good evidence that it would actually help them, the physician should take the time to explain, in a manner that will lead to understanding without alienating the patient, why that modality is unlikely to be of any help. The sad part is that physicians generally lack adequate time to have these discussions. The answer is not to integrate CAM practitioners and their methods into the mix, but to get more legitimate health care providers. That is a long-term goal, and one that we might not be able to reach. But in the short term, clearing up terminology could help improve matters tremendously.

@Taylor Walsh

Forgot to mention one thing. I have not yet had time to listen to the Perlam interview, but will when I get an opportunity.

Todd —( that’s Adam Perlman at Duke - sloppy typing by me). I meant that the concerns are receding within conventional medicine. At this point I don’t think it fair to suggest that highy trained physicians who are interested in CAM and integrated approaches are missing the main point, which is to bring all effective care to patients. The term “medicine” itself I think is coming to be more inclusive. Surely the pure controlled-trial evidence framework is too often unreliable, and the public sees this every time a drug gets pulled off the shelves, every time a group of highly experienced physicians examines the data and changes recommendations regarding the need for mammograms or prostrate exams, for instance. None of those events means homeopathy, for instance, has been proven effective. It does mean that medicine is starting to take a more expansive view on how evidence is defined. Plus, it is noteworthy that the patient is now becoming more central to defining research questions. So as medicine actually does move to be more “patient-centric,” patient interest in therapy options will become more, not less, important. We’re in a thoroughly transitional era it seems to me in which almost everything about medicine is being questioned. I don’t think the answers about some CAM elements are as clear yet as you believe them to be, so the research should continue, IMHO.

When I was a young nurse in 1975, I listened to a lecture about a “new paradigm” in nursing that would introduce “holistic” nursing, i.e. care of the whole person. The gray-haired nurse sitting next to me leaned over and whispered, “I thought we’d been doing that for decades already.” Holistic nursing was to dubbed a “new paradigm” again in the 1990s.

The “integrative medicine” movement is just old pre-science philosophy (quackery) dressed in up new jargon, with a heavy emphasis on “spirituality,” making it, indeed, a form of faith healing. Alas, NCCAM gives its imprimatur to unvalidated and invalidated practices by its mere existence. Its generous research grants for the study of practices with little or no plausibility amounts to unethical experimentation. It exploits human subjects and can potentially destroy the relationship between medicine and the public.

I see that we’ll have to disagree Linda. For my part, I am always interested in inquiry. A friend had a debilitating sinus infection a couple of years ago for which her docs tried all the therapies they knew. None worked for her. Several acupuncture sessions over about two months did work. And her relief continued without a recurrence. What happened for her? I don’t know, but would like to. Regrettably, her docs had no interest in knowing (rather: they may have an interest, but they aren’t paid to make the inquiry). We have learned a lot in the last decade about our biology that was previously unknown or has proven to be inaccurate or incomplete. We have many dedicated, trained and experienced men and women trying to understand these new views of our personal bioscapes. You may not agree with the basis for their work, but I hope you will try to have a more open mind about it. The public created NCCAM and the whole enterprise that we call integrative medicine. They’re really only interested in what works, which has included for 30+ years using this class of therapies we lump under CAM.

@Taylor Walsh

“Surely the pure controlled-trial evidence framework is too often unreliable” - What approach would you use instead of the controlled trial? It may have its flaws and shortcomings, but it is far from “unreliable” and is the best approach we have come across so far. You talk about drugs getting pulled from shelves as evidence that RCTs are unreliable, but you seem to misunderstand how the science works. We have limited resources (money, time, personnel, subjects, etc.) and so can only test new drugs, devices and methods on a limited group of people. The down side of that is that rarer side effects may not be found; it’s only when the new treatment makes it into the larger population that they may become apparent. That’s not a reason to suggest that RCTs, more often than not, should not be believed.

“A friend had a debilitating sinus infection a couple of years ago for which her docs tried all the therapies they knew. None worked for her. Several acupuncture sessions over about two months did work. And her relief continued without a recurrence. What happened for her?” - Probably regression to the mean.

“The public created NCCAM” - This is incorrect. NCCAM was created as a result of legislators with a very large CAM purveyor constituency (e.g., Sen. Harkin) pushing legislation through to create it. Harkin and his ilk wanted it to generate evidence to support CAM, though Dr. Briggs and some of her predecessors have done a decent job trying to remedy that and bring a more science-driven, rather than policy- or popularity-driven, focus to its aims.

On a final note, you mention that medicine is becoming more inclusive. I agree, but I disagree that that is a good thing where the majority of CAM is concerned. Most of the CAM supporters have this tendency to try to create a different set of standards of evidence for CAM, trying to exempt it from the rigors applied to real medicine. This can be seen, for example, in lots of acupuncture studies, where needling performs no better than placebo, to which the research cry “Well, then. Placebo must be an effective treatment!” This type of spin would never fly for a drug or medical device produced by a company like Pfizer or Merck. Medicine should be patient-centered (and I’d argue that the focus has always been on the patient and their medical needs). Bringing unproven and disproven nostrums into the mix does not improve matters. Instead, it just muddies the waters.

Todd, your view is very interesting. I know terminology matters a great deal in this world. But, no matter what you want to call all of these practices… complementary, integrative, medicine, non-medicine, wishful thinking, etc…, a large portion of our population utilizes them all the time for treatment of various illnesses. They are not asking their doctor for permission to seek alternative treatments nor do they need it legally. Do you think the government has any role in scrutinizing these practices?

NCCAM research is largely vanity research and has serious ethical concerns, for example:

– Are subjects fully informed that the experiment is highly unlikely to yield any results? If not, their consent it not voluntary, and that would constitute a violation of the Nuremberg Code for human experimentation.

– Are subjects informed that the experiment is based on poorly-formed hypotheses that violate established scientific knowledge and is therefore highly unlikely to yield any knowledge that can benefit humanity? If not, this constitutes several violations of the Nuremberg Code.

Considering the paucity of useable results by NCCAM/OAM research over the years, isn’t it premature to talk about “integrating” CAM into medicine? Isn’t it really time NCCAM’s millions in funding was diverted to serious and potentially useful research, e.g. in the study of orphan diseases?

Linda, I am curious as to what you are actually saying. Are you saying that IRBs nationally and abroad are simply not functioning? Their policies are unethical?

Additionally, If you want to acquire funding for the study of orphan diseases or whatever you personally deem “useful research”, gratuitous attacks on NCCAM and CAM research doesn’t seem like an effective use of your time to accomplish this.

@Pat Durning

I know that there are quite a few people that use CAM (though not as many as CAM proponents would have folks believe, since they lump in things like diet, massage, etc.). Regardless of that, even if every person in the U.S. used CAM every year, that would not be reason to call it medicine or to put it on equal footing with medicine by, say, teaching it in med schools or at large, well-respected hospitals. Or creating government agencies to give CAM its imprimatur. Medical practice should be based on sound science, not popularity.

As far as scrutiny is concerned, medical boards should ensure that medical practitioners uphold the highest standards of medicine. CAM practitioners, if they wish to practice medicine, should meet the same standards as real physicians. Physicians that want to offer CAM to their patients should likewise make certain that what they are offering is supported by valid science. This practice of medicine is the domain of the medical boards (and not lobbied CAM boards that simply rubber stamp licenses or engage in other corrupt activities, like the California board of acupuncture). Where government comes in is to protect consumers of health services from practices where the risks outweigh the benefits, as well as protecting them from fraud.

Frankly, if someone choose to spend their time and money on nonsense, that is their decision. I don’t think it’s a wise one, but they can do as they wish. Where I have a problem is with practitioners (even well-meaning ones) wasting patients’ time and money with false hope. And where I really have a problem is when those who are particularly vulnerable (e.g., children) are taken advantage of or harmed by these fringe notions.

Todd and Linda — we’re creeping into a game of “Yes, but…”. A last one for me: when I say consumers created NCCAM, I mean that their widespread use was noted by a researcher in the early 90’s at a time when a friend of Sen. Harkin’s had a positive experience with a CAM therapy. The research showed 15+ million Americans were using non-prescribed therapies to the tune of some $20 billion. That was 1993. Harkin said “we should know more about this.” But hospitals also started offering some therapies, as a matter of marketing mostly, and some still do that, only because of patient demand. Hospitals use social media for the same reason: responding to demand. As for accusations about vanity research, violating Nuremburg codes, and destroying the US medical system, you are going to have to include as co-conspirators the Institute of Medicine, the NIH, HHS, 50 of the nation’s pre-eminent medical schools, the US Dept of Defense and Veterans health systems, and the American Academy of Pediatrics, among others.

“Linda, I am curious as to what you are actually saying. Are you saying that IRBs nationally and abroad are simply not functioning? Their policies are unethical?”… “…you are going to have to include as [NCCAM’s] co-conspirators the Institute of Medicine, the NIH [etc]…” IF THE SHOE FITS…

@Taylor Walsh

It seems like you would support, then, the massive expenditure of scarce research dollars if a large number of people began demanding treatment to balance their humours? As you admit in your comment, much of the use of CAM can be attributed to marketing, as well as a rebranding of science-based modalities (like massage, diet, etc.) as “alternative” or “holistic”. The sad thing is that hospitals and medical schools have fallen victim to this marketing lure, as well, opting for increased income over integrity. Sen. Harkin helped promote this, thanks to his CAM purveyor constituency lobbying him. Getting back to my original comment, this illustrates the huge problem with language and terminology.

As to ethics violations, thankfully, most CAM research looks at self-limiting and subjective conditions. An acupuncture study, for example, examining whether acupuncture can shrink tumors would be incredibly unethical and should not be allowed by any IRB.

Did I say my last was “my last?” Sigh. Todd, in 1993, there was no CAM “purveyor” constituency, unless you consider the supplement industry, which pre-dated CAM. No special interest group was beating on Harkin’s head to fund the Office of Alternative Medicine at NIH (precursor to NCCAM). My comment about hospital adoption did not “admit” anything: it is an observation about how hospitals have often first dealt with consumer demand for alternatives (also for social media access). Which is a natural first reaction for any tradition-bound institution. The spa industry is doing the same now. As for “massive” expenditures, you have to be kidding. $120 million a year for research on actual therapies being used by MILLIONS of Americans, many (many) of whom report relief and/or restoration? Your off-hand assertion about my friend’s resolution of a crippling sinus infection via acupuncture may satisfy you. I say there is much left to learn. Our knowledge of our own biology and the medicine that might restore its compromises are by any measure imperfect and still unfolding (and lets leave aside the system that delivers it all). Lastly, it is worth noting that in the decade ahead the patient and the physician will be in much closer consultation, in the clinic or via this proliferation of (still-dubious) wellness applications. The understanding about the use and benefits and risks of ALL potential therapies will be defined in a very new evidence-based, whole-person, collaborative way, and that is how “integrative” medicine will continue to evolve and broaden our underlying concepts of health and how it is best supported.

Here is an example of NCCAM-funded research, research that never should have made it past an IRB: “Massage to Increase Well-Being and Immune Function in Dominican Children Infected With HIV” (http://clinicaltrials.gov/ct/show/NCT00070980?order=157). The hypothesis was impossibly weak; the protocol flawed for what the researchers were trying to measure; and the outcome predictably negative for touch therapy. This study is a crime against humanity since, in violation of the Common Rule that applies to all NIH funding of research no matter where conducted, the infant subjects diagnosed with HIV/AIDS were denied pharmaceutical therapy. When an IRB will pass on something as shockingly flawed, unethical, and inhumane as this study, it is no wonder that IRBs are found to approve NCCAM’s other studies with mystical-based “hypotheses.” I will admit that the problem is wider than NCCAM alone, but the wider problem makes it easy for NCCAM to exploit the public in many ways.

@Taylor Walsh

A bit of poking around would show that you are mistaken about there being no CAM purveyor constituency before 1993. There were definitely individuals hawking CAM nostrums and purported remedies well before 1993: reiki, homeopathy, orthomolecular nonsense, chiropractic, etc. Heck, homeopathy was written into the FDA regulations when they were first developed! There may or may not have been any special interest groups prior to the development of the OAM, but that does not mean that there were not influential individuals trying to get more power to practice their snake oil.

As to funding $120M a year is a good chunk of change, and there are many valid researchers who cannot get funding for worthwhile products because that $120M is funneled instead toward a variety of studies similar to the one Linda Rosa mentioned. NCCAM is getting better at choosing which studies to fund, but there is still an awful long way to go.

Regarding my suggestion of regression to the mean in your friend’s sinus infection case, it was not “off-hand” at all. Rather, considering what we know, it is the most likely explanation the requires the least extraordinary assumptions. You might also consider this study looking at acupuncture and sinusitis (http://www.ncbi.nlm.nih.gov/pubmed/18710490).

But again, getting back to my original point, CAM is, by definition, that which has either not yet been proven to work or has been proven not to work. Either way, it should not be a part of regular medical practice outside the confines of a clinical trial, and even then, there must be a reasonable basis (well-designed animal and in vitro studies that show a favorable outcome) to conduct the trials in people. Treatment by popularity does no one any good.

@Linda - Although I am concerned this is getting off-topic from “what is in a word” I feel I must respond and hold you accountable for what I perceive are uninformed comments that could be misperceived and perpetuated.
1) Your statement that this study was a “crime against humanity” is really over reactive. The control was not “denied pharmaceutical therapy”. The original article (and I’m sure the informed consent) indicates that several regimens to boost the immune system have been explored with limited results. Unfortunately, the most promising coadjuvant therapies are expensive and accompanied by severe secondary effects. Initial findings from pediatric studies of interleukin-2 treatment, for instance, reveal that a high proportion of children may have to discontinue therapy because of toxicity.
2) The fact that 86% of the children in the massage group showed an increase in CD4 cell count from baseline or remained stable (30% CD4 change) compared to 60% of the control group without toxic side effects is surely something to consider.

Todd — I guess the last, last thing to say is that the integrative horse has long since left the barn. I hope that over time you’ll see that your concerns and fears need not be as deep and as acute as they appear to be. For myself I hope to see more understanding of all the processes at work when therapies and healing practices are at work. New technologies and experiences are gradually redrawing the picture of those processes and outcomes, and the whole of it is in good hands, despite what you may think of the motivation of those professionals. 30 million duped Americans and thousands of duped health professionals? Sorry it just doesn’t compute.

Ms. Gomes: Regarding the above mentioned NCCAM-funded Dominican Republic study testing “touch therapy” on children infected with HIV, your efforts to salvage the reputation of NCCAM come too little and too late:

…”They were dying of AIDS but not taking antiretroviral drugs available in the United States at the time (not all clinical trials involve drugs or devices). The researcher paid forty-eight families $5 per clinic visit, twice a week for twelve weeks. The children were ‘randomized’ into two groups. One received therapeutic massage; the other, made up of twelve HIV-positive children, met with a nurse for ‘reading, talking, playing quiet games’ as part of ‘the friendly visit control group.’ When the study was finished, according to a report in *The Journal of Alternative and Complementary Medicine,* the researchers apparently packed their bags and left without offering any of the dying children life-saving drugs. ‘This is a terrible study for a number of reasons, including the fact that it is biologically implausible,’ says Marcia Angell, a senior lecturer in social medicine at Harvard Medical School and former editor of *The New England Journal of Medicine.* ‘This would have been impossible to do in the US. No reasonable IRB would approve it. The worst part is that this was supported by the NIH, which could afford to treat those children.’”

From: *Pulitzer Center on Crisis Reporting* and *The Nation*:
(http://pulitzercenter.org/articles/national-institutes-health-compromising-medical-ethics;
http://pulitzercenter.org/reporting/central-america-drug-clinical-trial-federal-regulations; http://www.thenation.com/article/163547/rise-unregulated-drug-trials-south-america?page=full)

Why would a person oppose “Integrative Medicine” and NCCAM? It’s because they are full of ideologues who defend studies such as this. Integrative Medicine is not about treating the “whole person” – it’s about exploiting human beings.

Recent study on use of acupuncture for hypertension:
Evidence-Based Complementary and Alternative Medicine.
Volume 2012 (2012), Article ID 878673, 9 pages
doi:10.1155/2012/878673

http://www.hindawi.com/journals/ecam/2012/878673/

Wei Zhou, Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA

John C. Longhurst, Department of Medicine, University of California Irvine, Irvine, CA 92697, USA

“Summary: Acupuncture has been shown to decrease BP (blood pressure) in hypertensive patients and in animal models of hypertension. The mechanisms underlying the beneficial effects of acupuncture are associated with modulation of sympathetic outflow and possibly the endocrine system. Experimental studies have shown that EA (electro-acupuncture) inhibits the reflex-induced hypertension by modulating the activity of cardiovascular presympathetic neurons in the rVLM. Activation of neurons in the arcuate nucleus of the hypothalamus, vlPAG in the midbrain, and NRP in the medulla by EA can inhibit the activity of premotor sympathetic neurons in the rVLM. Glutamate, acetylcholine, opioids, GABA, nociceptin, serotonin, NO, and endocannabinoids in the brain all appear to participate in the EA antihypertensive response (Figure 2). The central action of EA may also affect the endocrine system and lead to a decrease in plasma renin, aldosterone, angiotensin II, norepinephrine, and serotonin. The neuroendocrine mechanisms of acupuncture in the treatment of hypertension are not yet fully understood, and thus are worthy of further investigation.

( * * Note * * EA rather than manual acupuncture has been used in many studies on cardiovascular related diseases, because the parameters of EA can be precisely controlled so the results are reproducible, whereas the outcome from manual acupuncture is operator dependent and therefore, is not as reproducible. )”

Here is an example of another highly unethical CAM study carried out in a Third World country:

http://www.sciencebasedmedicine.org/index.php/on-the-ethics-of-clinical-trials-of-homeopathy-in-third-world-countries/

Remember, most homeopathic remedies are diluted to the point where they are indistinguishable from water. There is no way this therapy could have worked, but children with infectious diarrhea were subjected to it anyway.

And here’s another even more unethical CAM trial that was funded by NCCAM:

http://www.sciencebasedmedicine.org/index.php/evidence-based-medicine-human-studies-ethics-and-the-gonzalez-regimen-a-disappointing-editorial-in-the-journal-of-clinical-oncology-part-1/

http://www.sciencebasedmedicine.org/index.php/tom-harkin-nccam-health-care-reform-and-a-worse-than-useless-cancer-therapy/

I find it fascinating how those who oppose “CAM” and “integrative medicine” immediately polarize - just as many in the CAM/IM world quickly point out at these moments that up to 50% of “conventional” treatment is waste. (See: http://jama.jamanetwork.com/article.aspx?articleid=181387) Todd W begins with: “When it comes to “integrative”, it would be particularly helpful and beneficial to patients to make clear that when CAM proponents talk about ‘integrative medicine’, what they are really saying is that they wish to integrate the unproven or the dis-proven with medicine.” Is the 30%-50% that is waste all evidence-base wastefulness? Todd W must know that regular medicine is on shakey ground from an evidence perspective. Todd W’s comment would have better portrayed the depth of our problems if he said that IM is those who “want to integrative the unproven or the dis-proven with the unproven and dis-proven in regular medicine.” Why polarize? Dr. Briggs’ question was not about whether the sky is falling. She asked about the term “integrative.” My view is: While the term is useful - and I use it a lot - it is potentially a dangerous estrangement from the roots of what her agency was charged to explore: alternative modalities, systems and disciplines. We have seen from the response to “integrative health” and “integrative practitioner” language in the Affordable Care Act that many read these as the integration of MDs with nurses and psychologists and PTs. While this reflects a positive step toward team care, its does not reflect the public interest in what has been non-conventional (chiropractic, naturopathic medicine, acupuncture and Oriental medicine, etc.). These are what NCCAM is charged to explore. At this time in the evolution of the “integrative” dialogue, the so-called complementary and alternative health disciplines and practices must continue to be explicitly included or they will, likely, be excluded. Finally, the term “integrative” is a political one which is meant to not chafe as much as “alternative” to conventional doctors. Yet, in the area Briggs mentions of non-pharmacological management of pain, I’d say that changing the therapeutic order towards using non-opiod “CAM” treatments and practitioners first (rather than only when all else fails) is actually an “alternative” to typical practice. This is an alternative toward which we should be striving, even if it is discomforting to some who practice differently.

One of the big components of getting well (besides the doctor/patient or health practitioner/client relationship) is for the patient/client to be PROACTIVE WITH THEIR HEALTH. I am not sure I read any such comments pertaining to this very important component of a person’s health. Perhaps that’s the real paradigm for health and medicine in the 21st century. There is another extremely important piece of this wellness and health topic, and that is the mind - body connection. Medical science is collecting more data all the time that shows things such as Mindfulness or Meditation as a valid process that has a rightful place in treating our health (even the military uses meditation — http://full-contact.military.com/2011/11/11/the-u-s-marine-mindfulness-meditation-program/).

I received my training at Duke Integrative Medicine Health Coaching Foundation, Durham, N.C. You will notice the word “Integrative” in the name of their foundation. I also use that word for my business name (Integrative Wellness Partner). I use a blend of health coaching, nutritional coaching, and exercise coaching to help clients obtain the lifestyle results they are seeking for wellness. I have certifications in nutrition, as a personal trainer, Food As Medicine (CMBM), herbal studies, homeopathy, reiki (II), Bach Flower Remedies, and aromatherapy. I am also a culinary expert that bases meal preparation on nutritional value and the positive effects it has on health (food as medicine). Any responsible health practitioner will take the time to research reputable sources and keep up to date with various health breakthroughs, health modalities (prevention and intervention), supplements and herbs, drug and herbal reactions, drug and food reactions, etc., before discussing such a treatment or remedy with a client/patient.

As a health coach, it is my responsibility to help my client gain clarity on their situation or challenge, strategize for overcoming challenges, and support them in their steps to accomplish positive outcomes. Educating the client is appropriate at times, in terms of looking at their real options for their particular situation or condition and possible outcomes (i.e., helping a diabetic figure out the best way to eat appropriate meals on days they are extra busy with work, family, and/or physical activity…What would happen if nutritious meals were prepared a few days ahead for those extra busy days?).

As an Integrative Health Coach or Partner, it is my job to assist the client in the best way possible, so that, in short, they can make those changes (and decisions) in their life that have value and positive short and long term results. Again, the key is that the client or patient be proactive in the whole process of their own wellness.

Hi Adrian, many thanks for adding the reality of your experience and training, which I hope becomes widespread, and quickly. The health coach/mentor/partner role will go a long way to filling the sizable gaps in the information that consumers are going to be expected to have at their hands as they learn how to be proactive for their (our!) own behalf. Duke has to be commended for advancing “integrative” via the broad scope you describe. At some point, I also hope the question of affordability gets resolved. Having models like Duke IM in place may prove the point and show the longer (not too long!) gains in individual health and wellbeing, and the reduced cost of health for those you work with. NCCAM is also studying the nutritional and behavioral aspects of some of these wellness factors, as well as the therapeutic qualities of healing and care options.

Modern medicine is very much disease orientated integrating technology and striving to be evidence based. In this process did we forget the human touch?

Complementary and Alternative Medicine appeals to public as evidenced by its increased usage and our openness to and interest in such modalities.

Consumers feel CAM as not taking medication but something natural. Providers of CAM have better skills in appealing to the human in their consumers. They talk positively with compassion to their consumers. Are such providers more healers than just technicians?

Interest in CAM and increased efforts research wise will bring CAM modalities to mainstream of medicine. Then it will be alternative no more as happened in case medications like aspirin or digoxin, integrates naturally.

Eventually there will be only Mind Body Medicine to integrate. MBM is not just for the consumers but also for the providers. Providers need to be practitioners of such as meditation, yoga asana, pranayama, qigong etc., which will help incorporate these in a better way to the benefit of health, holistic.

One system medicalizes other humanizes?
Integration will be less medicalization with more humanization compassionately?
Then just one medicine!

Best wishes NCCAM in such efforts.

It is so great to hear professionals such as your self finally treating alternative therapies with the proper time and consideration they deserve and not just as “hocus pocus”!

“In this process did we forget the human touch?” As a nurse, I take this as an insult to my profession.

I am not much into looking at, but somehow I got to go through many articles articles on your website. Its incredible how useful it is for me to check out you very often.
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I found this dialoge very eye-opening as some still seem to see the public as not having any real say or imput worth hearing about,about their own bodies. Are we really supposed to leave it all to proven science? Are we really just then to be treated like so many lab rats, or tuskeegee experiments? I know that some may find this insulting and I AM sorry for that but CAM is in the public’s eye because the public believes that mordern scientific medicine could be curing things that they are just treating now because treating symtoms is more profitable.I am training to be a health coach because I believe the future is a CAM model of medicine for this country and that that is a very positive step in the right direction.To think that anything spiritual has no business in the treatment of humans is to ignore thousands of years of proof that we are more than just a collection of chemical processes that respond only to the exact manipulation by a few who know better than we do about our bodies but either don’t have the time or the training to speak to us in a way that has real meaning. Most doctors I have spoken to who have practiced for any real period of time will tell you they know of a case that defied what is considered the norm. If the person who lives 10 years longer than expected by sheer will, or through nutrition, or herbal remedies is your family member would you feel the same way about CAM? Thank you for your time and the wonderful information on this site. 

@Ed Cotter ”Are we really supposed to leave it all to proven science?” Yes, for the simple fact that it is the best means we have to reliably know what it likely to work and what isn’t. ”Are we really just then to be treated like so many lab rats, or tuskeegee experiments?” Despite your misrepresentation of scientific medicine, every treatment, whether science-based or “CAM”, ultimately treats the patient as a “lab rat”, since we can never know with absolute certainty whether a given treatment will work for a particular individual. We can be reasonably sure of the outcome, but since each person is different, we can’t be 100%. Science-based medicine, however, gives us the greatest amount of confidence in the likely outcome, though. As for Tuskegee, of course we are not to be treated that way. That’s why we have developed a variety of ethics reviews, and why science-based medicine (as opposed to many CAM treatments) have to go through such hoops to gain approval for use. ”If the person who lives 10 years longer than expected by sheer will, or through nutrition, or herbal remedies is your family member would you feel the same way about CAM?” Yes, I would. You know why? Because, as was mentioned already, those things which have been shown to work through scientific inquiry and examination are what we call “medicine”. Everything else either has not yet been proven to work or has been proven not to work. If you want to advocate for the use of some CAM modality, then pony up the evidence that it a) actually does something, b) that the something it does is clinically meaningful and c) that the benefits outweigh the risks (and not just adverse effects, but also the risk of choosing it over conventional treatments).