To Your Health -- CHRC Newsletter

Winter Issue 1999

Written By: Laurel Trujillo, MD, PAMF Internal Medicine,

There has been a dramatic increase in public interest and awareness of alternative therapies in the past several years. What exactly is alternative medicine? Unfortunately, the definition is not standardized. "Complementary," "alternative," and "integrative" are all commonly used terms applied to multiple different therapies. For example, some would consider chiropractic as "alternative," where others view it as part of the mainstream. For the purposes of this article, I will adopt the definition used by Eisenberg in his initial study from 1990: "Interventions neither taught widely in medical schools nor generally available in hospitals". ⁽¹⁾ Using this definition, let's look at what is known about who uses complementary/alternative medicine (CAM) and why.

The first study of the use of CAM was a telephone survey of 1,539 randomly selected Americans over the age of 18 which was done in 1990 by David Eisenberg, M.D., and colleagues, and published in the New England Journal of Medicine in 1993. One-third of those surveyed reported using at least one alternative therapy to treat a serious or bothersome medical problem during the past year. One patient out of 10 self-paid for 19 visits in the preceding year, mostly for chronic medical conditions rather than life-threatening ones. Seventy percent of those who used CAM did not tell their medical doctors that they were using any alternative therapies.

From these figures, it was estimated that in the United States in 1990, there were 425 million visits to CAM providers. This exceeded the number of visits to primary care providers and cost approximately $10.3 billion, most of which was not covered by insurance. This cost was similar to the $12.8 billion out-of-pocket cost for all U.S. hospitalizations in the same year. This study has been criticized for having an overly broad definition of alternative therapies, as the authors did not exclude either self-help groups or commercial weight loss programs. Even with these criticisms,the study showed that the use of CAM was far greater than had been previously thought.

The most popular CAM therapy reported in Eisenberg's study was some form of relaxation (including meditation), which was reported by 13 percent. Ten percent reported using chiropractic and seven percent used massage. Two to four percent each used herbal remedies, macrobiotics, megavitamins, imagery, self-help groups or spiritual healing. One percent each reported using acupuncture, biofeedback or hypnosis. Eisenberg's study was recently repeated, showing an overall increase in the number of people reporting CAM use from 33 percent to 40 percent.

There is also data available from people living in the Bay Area. In 1995, the San Francisco Chronicle and KRON TV conducted a telephone poll of 600 adults. More people (41 percent) in the San Francisco Bay Area use alternative therapies than in the country as a whole. More than one-fourth had used two or more different CAM therapies within the past year. Half of those who saw a medical doctor in the past year also reported using alternative therapies, and greater than 50 percent were likely to use alternative therapies in the future. Ninety-one percent reported being satisfied with the results they received from CAM therapies.

Relaxation was again the most common therapy, reported at 17 percent. There was more use of massage (15 percent), herbs (13 percent), macrobiotics (13 percent), megavitamins (8 percent), spiritual approaches (7 percent), imagery (6 percent), and self-help groups (6 percent) than in the rest of the country. Two percent of the respondents each reported using biofeedback and acupuncture. Hypnosis rates were the same in the Bay Area as elsewhere (1 percent).

The United States is not the only country with a documented use of alternative therapies. International studies show use in from 25 to 75 percent of the populations of the United Kingdom, Australia France, Germany, Israel, Finland and Japan.

The Netherlands also uses alternative therapies. In China and India the majority of medical care is provided by "traditional" providers practicing acupuncture and ayurveda (both of which are considered "alternative" in this country). Homeopathy is reimbursed by the National Health Service in the United Kingdom and by private insurers in Germany.

As these data indicate, there is widespread use of complementary/alternative therapies in the United States. Given that most people have to pay for these treatments, and that many are not yet proven to be effective, why do people seek out such therapies?

One very interesting study addressing this question was published in 1998 in the Journal of the American Medical Association.⁽²⁾Astin conducted a written survey of 1,035 patients regarding their use of CAM therapies and the reasoning behind it. Astin proposed three possible explanations for people's use of Alternative Therapies: Dissatisfaction, Personal Control, and Philosophical Congruence. "Dissatisfaction" supposed that people used CAM therapies because they felt conventional treatments were ineffective, had too many adverse effects, were too impersonal, technologically oriented, or too costly. The "Personal Control" theory proposed that people who used CAM therapies valued the personal autonomy and control over health care decisions that may be provided in Alternative Therapies. These are often viewed as less authoritarian and more empowering to the individual patient. Lastly, the "Philosophical Congruence" model proposed that CAM therapies were appealing because they better matched the person's values, world view, or beliefs regarding the nature and meaning of health and illness.

A questionnaire designed to test these three theories was mailed to a random sample of people who had previously agreed to participate in mail surveys. Sixty-nine percent of the sample completed the questionnaire. Of this population, again 40% had used CAM therapies within the past year. In this group, Alternative Therapy users were more likely to report these diagnoses: anxiety, back problems, chronic pain, and urinary tract problems.

Several factors were identified as independent predictors of Alternative Therapy use: More education, poorer self-reported health status, and having a holistic orientation to health (meaning the belief that body, mind and spirit are all considered important in health and illness).

Having had a transformational experience (an experience that changed the person's world view) was also a predictor of using CAM. Neither dissatisfaction with conventional medicine nor valuing personal control were predictors of CAM use.

When asked to describe the benefits of Alternative Therapies, comments regarding the effectiveness of such therapies were given twice as often as any other response. Common responses included: "I get relief for my symptoms, the pain or discomfort is less or goes away. I feel better." The next most common response was "The treatment promotes health rather than just focusing on illness". Therefore, the study supported the "Philosophical Congruence" theory, but not the other two. Interestingly, only 4% reported using only Alternative Therapies, meaning that the vast majority of people seek care from both Conventional and Alternative providers.

Summary

Complementary/Alternative Medicine is quite commonly used, especially in the Bay Area. Data exploring the reasons why people use CAM are somewhat limited, but suggest that people use such therapies because they match their own values and world view, including a more holistic approach to health and a focus on prevention.

A review of the scientific evidence about specific alternative therapies is beyond the scope of this article. Several references are available in the Community Health Resource Center including:

1. Rational Phytotherapy, A Physician's Guide to Herbal Medicines. Schulz, Volker, et al..


2. The Honest Herbal, Tyler, Varro, PhD. (Dr. Tyler is the Dean and Distinguished Professor of Pharmacognosy Emeritus at Purdue University).


3. AMA Reader's Guide to Alternative Health Methods. Describes each alternative therapy and reviews both the critical and proponent literature.


4. The Alternative Advisor: the Complete Guide to Natural Therapies and Alternative Treatments. Time/Life Books.


5. Dr. Rosenfeld's Guide to Alternative Medicine, Rosenfeld, Isadore, MD.


6. German Commission E Monographs: These monographs review the scientific evidence of efficacy for 190 herbs, and include information on approved uses, contraindications, and known side effects.

References

1. Eisenberg, DM, et al. Unconventional Medicine in the United States: prevalence, costs, and patterns of use. NEJM. 1993: 328:246-252.


2. Astin, JA. Why Patients Use Alternative Medicine: Results of a National Study. JAMA. 1998; 279:1548-1553.

On the Bookshelf

The Women's Health Resource Center has many excellent books for your perusal.

Here are descriptions of three:

The Healthy Mind

Healthy Body Handbook

David S. Sobel, MD

Robert Ornstein, Ph.D.

Patient Education Media, Inc.,

New York, 1996

Mind-Body medicine is the combination of ancient practices and modern science. Physical and psychological interaction and balance result in a sense of wellbeing. Based on their vast clinical experience as well as scientific evidence, the authors, a physician and a psychologist, discuss their belief that body systems are affected by one's thoughts, emotions and behaviors, e.g., laughter reduces pain; optimistic thinking enhances immunity. In the section "Staying Well" healthy thinking, relaxation, imagery, sex, exercise, communication and altruism are addressed. In another section anxiety, depression, anger, sleep problems, trauma, addiction and chronic pain are discussed and coping strategies are offered. An extensive list of resources is included at the end.

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Multiple Sclerosis:

A Guide For Families

Rosalind C. Kalb, Ph.D.

Demos Vermande,

New York, 1998

MS, often diagnosed in young adulthood, affects the individual not only physically, but also in such decisions as career, marriage and child rearing, retirement and care of elderly parents. It can cause a disruption in daily routines, rhythms and communication. Family roles may change. Feelings of guilt, anger and sadness may create obstacles to intimacy, growth, joy and family unity. This comprehensive book has chapters that discuss the relationship with the healthcare team; finances and life planning; fertility, pregnancy and child rearing; sexuality and intimacy, and the care giving relationship. The family is encouraged to find balance between the needs of its members, and the limitations imposed by MS in order to cope with the challenge of living with a chronic disease.

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When Men Grieve

Elizabeth Levang, Ph.D.

Fairview Press, Minneapolis, Minnesota, 1998

Although grief is a universal experience, most of us are unprepared for the feelings it brings. Grief causes disruption of our familiar and comfortable reality and completely changes our lives. It is as unique as we are. Men and women have different ways of grieving. Whereas women are more open, feeling and verbal about their grief men tend to think their way through grief. They keep their pain private and say that they cannot put their loss into words. They often distract themselves in order to go on with the business of living. Men, more than women, may seek substitutes for reality and intimacy by engaging in addictive remedies to ease their pain. Through this book you will learn about the differences, and ways to nurture a supportive relationship with your partner, so that each of you can grieve and heal in your own way.

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