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Complementary and alternative therapies (CAM) are used by many types of providers, including physicians, nurse practitioners, chiropractors, dentists, naturopaths and self-styled practitioners.1 The federal government acknowledged the significance of CAM by establishing the National Center for Complementary and Alternative Medicine (NCCAM), an independent component of the National Institutes of Health (NIH).2

The NCCAM has defined terminology related to his growing healthcare area. "Complementary medicine" refers to therapies used with conventional medicine, often called allopathic medicine. "Alternative medicine" encompasses therapies used in place of conventional medicine. "Integrative medicine" refers to the combining of conventional medicine with CAM. Some high-quality evidence about the safety and effectiveness of integrative medicine is available in the literature.3

Four Domains
The NCCAM has delineated four domains of complementary medicine: mind-body medicine, biologically-based practices, manipulative and body practices, and energy medicine.

Mind-body medicine employs techniques to enhance the mind's capacity to affect bodily functions and symptoms (cognitive behavioral therapy, support groups, meditation, prayer, art, music and dance). Biologically-based practices consist of substances based in nature (foods, herbs, vitamins and natural but scientifically unproven therapies). Manipulative and body-based practices originate in the manipulation or movement of one or more body parts (massage, chiropractic and osteopathic medicine).3

Energy medicine focuses on the use of energy fields; this branch of CAM is not well supported by evidence at this point. Biofield therapies use energy fields proposed to surround and penetrate the human body. These energy therapies are applied by touching, manipulating the body, or by placing a hand above and in close proximity to the body (e.g., Reiki, qi gong, therapeutic touch). Bioelectromagnetic therapies employ the unconventional use of electromagnetic fields (pulsed fields, magnetic fields and alternative or direct current fields).3

The NCCAM also created the concept of whole medical systems, built upon complete systems of theory and practice. Two of the systems used in western medicine are homeopathic medicine and naturopathic medicine. The founder of homeopathy, German physician Samuel Hahnemann, advocated the examination of all aspects of a person's health status. He said treatments should be formulated by matching the symptoms produced by the intervention to the symptoms experienced by a patient (like cures like).4

The practice of homeopathy has declined, but naturopathy, which emphasizes a natural health approach (herbs, nutrition, body manipulation), appears to be increasing.5 Other non-western medical systems gaining in popularity include traditional Chinese medicine and ayurveda (the science of life), a whole medical system originating in India and derived from Hinduism and Persian beliefs. Ayurveda focuses on the integration and balance of body, spirit and mind. It encompasses it own complementary therapies, including herbs, yoga and massage.6

Selected Studies
The two earliest and most often cited surveys to examine the use and impact of CAM gathered data in 1990 and 1997.1 Researchers conducted random telephone surveys of 1,539 adults in 1990 and 2,055 adults in 1997 to determine the outcomes of alternative therapies. Nearly 34% of respondents used at least one alternative therapy in 1990, and approximately 42.1% used at least one in 1997.1

Of the 16 therapies named specifically in the survey, the 1997 group reported increased usage of 15 of the 16 therapies, with 10 of these increases demonstrating statistical significance. The largest increases occurred in the use of herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing and homeopathy.1 Both surveys found that less than 40% of people who used alternative therapies disclosed this practice to their providers. In 1997, 16.4% of prescription drug users took prescription drugs concurrently with herbal remedies and high-dose vitamins.1

The 1997 study emphasized the economic impact of using alternative therapies. The researchers estimated that visits to alternative practitioners exceeded the projected visits to U.S. primary care physicians by approximately 243 million visits. Nearly half of all visits to alternative practitioners were to chiropractors and massage therapists. Other commonly used alternative therapies were hypnosis, biofeedback and acupuncture.1

In a study conducted in l998-l999 (the Slone Survey), researchers examined medication CAM usage by 2,590 participants 18 and older.7 Medications were defined as prescription, OTC, vitamin or minerals and herbals or supplements. Eighty-one percent of the participants acknowledged taking at least one medication during the preceding week, 50% took at least one prescription drug, and 7% used five or more prescription drugs.7

Women 65 and older exhibited the highest overall medication usage, with 94% taking at least one medication during the previous week. Of the older women, 12% took at least 10 prescription medications and 23% took at least five. Fourteen percent of the respondents reported using herbals or supplements, and 16% of the prescription drug users took herbals or supplements concurrently. Men between the ages of 18 and 44 exhibited the lowest prevalence of medication usage, with 68% taking at least one medication, 7% taking at least five, and fewer than 1% taking 10 or more. Prescription drug use by men 65 and older was higher: 19% used at least five prescription drugs.7

Fourteen percent of the study population reported taking at least one herbal or supplement in the previous week. The most commonly used were ginseng, ginkgo biloba extract, garlic and glucosamine (tied), St. John's wort and echinacea (tied), lecithin, chondroitin, creatine and saw palmetto. Middle-aged men and women used herbals and supplements most often, and younger men were the most frequent users of creatine. Older men used glucosamine and Serenoa repens most often, while older women used ginkgo biloba more frequently. Sixteen percent of prescription drug users reported taking one or more herbal supplements. Of the people who used the 40 most common OTC and prescription drugs, the concomitant use of herbals or supplements in the same 1-week period ranged from 7% for paroxetine (Paxil) users to 20% for simvastatin (Zocor) users, to 20% for conjugated estrogen users and 22% for fluoxetine (Prozac) users.7

Adverse reactions to drugs are among the leading causes of hospitalization and death in the United States. There is increasing evidence that adverse interactions may occur when herbals are taken concurrently with prescription medications.7 Patients who use herbals or supplements often take them with little knowledge of their potentially adverse interactions with prescription or OTC medications.7

CAM Therapies for Nurse Practitioners

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