Complementary and Alternative Medicine
Li-Xing Man
Nicholas C. Sorrel
A landmark survey by Eisenberg et al. (1) in 1993 surprised the medical community by revealing that over one-third of Americans used unconventional therapies for health and well-being. Three-quarters of these individuals did not inform their physicians of this practice. In a followup study, Eisenberg et al. (2) found that the prevalence of unconventional therapy use increased from 33.8% in 1990 to 42.1% in 1997. The most recent data from the 2007 National Health Interview Survey (NHIS) show that 38.3% of American adults and 11.3% of children had used a complementary and alternative medicine (CAM) in the past year (3). Estimated expenditures on CAM increased 25.6% between 1997 and 2007, with 22.0 billion dollars spent on CAM products and 11.9 billion dollars spent on 354.2 million CAM practitioner visits annually (4).
CAM usage is similarly common in other countries. In 2004, an estimated 52% of the Australian population had used a CAM therapy in the last year (5). A 2005 survey by the Canadian government found that 71% of Canadians had used a natural product in their lifetime, with 38% of this group using them on a daily basis (6). In Germany, approximately 60% of adults had used a natural or alternative healing method in the preceding year (7).
The use of CAM therapies has increased over the past several decades, and trends indicate that utilization will continue to increase (5,8). This burgeoning interest in CAM treatments can be monitored in the popular press, in bookstores, and on the internet. Formal courses on CAM have been introduced into the medical school curriculum (9), and a number of peer-reviewed journals are dedicated to CAM topics. The U.S. Congress established the National Center for Complementary and Alternative Medicine (NCCAM) in 1998 to support scientific research and disseminate evidence-based safety and effectiveness information on CAM practices.
The widespread popular interest in, and utilization of, alternative and complementary therapies has led to a corresponding movement in the mainstream medical and scientific communities to incorporate these modalities into existing realms of teaching, clinical practice, and research. Attempts at trying to develop a nomenclature for these modalities in the 1990s led to terms such as “unconventional,” “nontraditional,” “unorthodox,” and “holistic.” These terms had the characteristic of revealing cultural values and judgments regarding the appropriateness and legitimacy of these therapies and treatments (10). “Complementary medicine” refers to the use of modalities in conjunction with conventional medicine, such as the use of acupuncture in addition to the usual care to control and lessen pain. “Alternative medicine” refers to the use of treatments and therapies in place of conventional medicine. Over the past decade, the most widely accepted term has been “complementary and alternative medicine” (CAM). The NCCAM defines CAM as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (11). More recently, the term “integrative medicine” has become increasingly utilized. This designation reflects the attempt to assimilate legitimate CAM therapies into the continuum of mainstream health care. It refers to a practice that combines both conventional and CAM treatments for which there is evidence of safety and effectiveness. According to Snyderman and Weil (12), integrative medicine “has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship.”
This chapter gives an overview of the most prevalent CAM modalities, reviews common CAM products and treatments that may have implications for the otolaryngology patient, and reviews CAM treatments for common otolaryngologic problems. Evidence on both the safety and efficacy of CAM modalities continues to evolve. Health care practitioners must be aware of the use of natural products
because of potential adverse effects and interactions with other medications. This chapter does not attempt to present every CAM product or therapy used for an otolaryngologic problem. Rather, it focuses on those modalities that have the most evidence, with an emphasis on randomized controlled trials (RCTs). In this chapter, the authors are in no way advocating the use of the therapies discussed. Knowledge of the clinical efficacy as well as adverse effects of these treatments is necessary so that otolaryngologist/head and neck surgeons can appropriately guide their patients, especially since most individuals using CAM therapies do not disclose their use to their physicians. Possessing an understanding of CAM practices and treatments improves physician-patient communication and enables the health care practitioner to better serve his or her patients.
because of potential adverse effects and interactions with other medications. This chapter does not attempt to present every CAM product or therapy used for an otolaryngologic problem. Rather, it focuses on those modalities that have the most evidence, with an emphasis on randomized controlled trials (RCTs). In this chapter, the authors are in no way advocating the use of the therapies discussed. Knowledge of the clinical efficacy as well as adverse effects of these treatments is necessary so that otolaryngologist/head and neck surgeons can appropriately guide their patients, especially since most individuals using CAM therapies do not disclose their use to their physicians. Possessing an understanding of CAM practices and treatments improves physician-patient communication and enables the health care practitioner to better serve his or her patients.
TYPES OF CAM
The myriad and diverse products and practices that encompass CAM are often organized into broad categories, such as natural products, mind-body medicine, manipulative and body-based practices, whole medical systems, and other CAM practices. Natural products include herbal medicines, vitamins, and minerals. Mind-body medicine includes meditation, yoga, prayer, and biofeedback. Manipulative and body-based practices include spinal manipulation and massage therapy. Whole medical systems include Ayurveda, traditional Chinese medicine (TCM), homeopathy, and naturopathic medicine. Other CAM practices include a range of movement therapies as well as energy therapies. These categories are somewhat overlapping, and some CAM practices may fit into more than one domain. For example, acupuncture is often categorized within mind-body medicine, but has elements like TCM, manipulative and body-based practices, as well as energy medicine (11).
Natural Products
CAM natural products include the use of herbal or botanical medicines, vitamins, and minerals. This domain also includes probiotics, which are live organisms—usually bacteria—that may confer beneficial effects to their hosts. Probiotics are available in foods, such as yogurt, or as dietary supplements. Herbs or botanicals with medicinal qualities represent some of the earliest attempts to improve health and well-being. They are the foundation of most folk remedies and are the cornerstone for many medical systems. A number of modern drugs used in mainstream medical practice were derived from plant sources. For example, the malaria treatments quinine and artemisinin were isolated from the bark of the genus Cinchona (a tree native to South America) and the plant Artemisa annua (an herb described in “Traditional Chinese Medicine”), respectively.
Many natural products are sold over the counter as dietary supplements and represent the most popular form of CAM use among both adults and children in the United States. The 2007 NHIS found that 17.7% of American adults had used a nonvitamin/nonmineral natural product in the last year (3,11). The most commonly utilized product among adults was fish oil or omega-3, which was used by 37.4% of those who reported using natural products. Other prevalently used natural products included glucosamine (19.9%) and echinacea (19.8%). Over one in ten of those surveyed reported using ginkgo biloba.
Mind-Body Medicine
These approaches focus on the relationship of the mind and body, brain and behavior. Many ancient and indigenous medical systems emphasize this interconnection. Over time, the theory advanced by Descartes of a separation of mind and body became a dominant concept among Western physicians, psychiatrists, and psychologists. Scientific healing in the form of drug therapy and surgery evolved to become the primary Western form of treatment. Over the last several decades, there has been a reemphasis in exploring the mind’s ability to affect the immune system as well as other organ systems. The fundamental tenets of mind-body medicine are the concept of treating the whole person and that individuals can be active participants in their own health care (13).
Mind-body techniques include psychotherapy, relaxation, meditation, hypnosis, biofeedback, and yoga. Psychotherapy refers to the treatment of emotional and mental health, which is interwoven with physical health. Relaxation techniques aim to manage and reduce stress. Meditation is a self-directed practice for the purposes of relaxing the mind and body. Some meditation techniques involve focusing attention on single thoughts or words, while others entail focusing on a physical experience such as a breath or a specific sound. All meditation techniques share a common goal of calming mental activity, incessant thoughts, and negative reactions to one’s environment or circumstances. In hypnosis, an altered state of mind is induced in which the patient enters into a state of deep and focused concentration and is receptive to specific suggestions. Biofeedback involves the use of instruments that translate physiologic processes into audio or visual signals. Patients can adjust their mental processes to control brain wave activity and bodily processes previously thought to be involuntary by observing monitoring devices. The origins of yoga date back to about 1500 BC in present-day India and Pakistan. As the practice of yoga spread throughout the world, myriad schools of thought and styles of practice have developed. Many people now understand yoga to be a practice of postures, breathing exercises, and cleansing practices, but at its root yoga is the mental process and discipline through which the human consciousness is unified with the divine consciousness (14). The practice of yoga
attempts to achieve harmony between the individual and surrounding universe by bringing the physical body under the control of the mind.
attempts to achieve harmony between the individual and surrounding universe by bringing the physical body under the control of the mind.
Acupuncture may also be categorized within mindbody medicine. Derived from TCM techniques, acupuncture is a family of procedures involving the stimulation of specific points located along channels corresponding to the flow of energy through the body. Traditionally, these acupoints were stimulated using fine filiform needles (0.12 to 0.46 mm diameter) to penetrate the skin. Modern acupuncture has evolved to include the application of electric currents, pressure, and low-intensity lasers to stimulate the acupoints. Moxibustion is often utilized in combination therapy with acupuncture. Moxibustion involves using heat either on or close to the skin to affect the flow of energy in the channel (15).
Several mind-body techniques were among the most commonly used CAM therapies used by American adults in the 2007 NHIS. The survey found that 12.7% had used deep-breathing exercises, 9.4% had practiced meditation, and 6.1% had practiced yoga in the past 12 months (3). An estimated 3.1 million adults and 150,000 children had used acupuncture, a 48% increase compared to the 2002 NHIS.
Manipulative and Body-Based Practices
Manipulative and body-based techniques focus primarily on touching, massaging, and manipulating the physical body to provide healing (16). Common therapies in this domain are osteopathic or chiropractic spinal manipulation and massage therapy. The 2007 NHIS estimated that 8.6% of American adults and 2.8% of children used osteopathic or chiropractic manipulation, while 8.3% of adults and 1% of children had used massage (3,11). Movementbased therapies include Feldenkrais bodywork, Alexander technique, Trager Psychophysical Integration, Aston patterning, and Pilates.
Osteopathic Medicine
Osteopathic medicine was developed by the allopathic physician Andrew Taylor Still in 1874 when he became disenchanted with the crude techniques and harmful effects of the medicines used by doctors practicing along the 19th century American frontier. After the American Civil War, during which he practiced allopathic medicine while serving as a hospital steward in the Kansas Infantry, Still became disaffected with conventional medicine in 1864 after three of his children died in a meningitis epidemic. He quit medical practice and devoted time to investigate the relationship between structure and function in the body. By 1874, he had defined the principles and philosophy of practice of osteopathy. Still’s primary tenet was that structural abnormality causes functional abnormality, leading to illness. Treatments were designed to use the body’s own resources. Manipulation was used to promote appropriate blood delivery, lymphatic return, and transmission of neural impulses to restore health (17). Common forms of osteopathic manipulative treatment (OMT) used today include high-velocity low-amplitude thrust, muscle energy, counterstrain, and cranial osteopathy. Craniosacral therapy is a simpler variant of cranial osteopathy that is practiced by nonphysicians such as physical therapists and massage therapists.
Osteopathy has evolved differently in the United States and in other parts of the world. Internationally, osteopathic medicine has diverged into two branches, nonphysician manipulative medicine osteopaths and osteopathic physicians practicing the full scope of medical practice. In the United States, osteopaths always have been physicians and have the same practice rights as allopathic physicians. Current practitioners implement the osteopathic medical philosophy to varying degree along a continuum of medical care (17). Only a small percentage of osteopathic physicians limit their practice to OMT, many practice no manipulation at all, and some do not believe in the clinical efficacy of OMT at all.
Chiropractic Medicine
Daniel David Palmer, a self-taught healer in Davenport, Iowa, founded the chiropractic profession in 1895. Palmer believed that the body had “innate intelligence”, or a natural healing ability (18). He theorized that “vertebral subluxation” (spinal misalignment causing abnormal nerve transmission) was the cause of disease, and that chiropractic adjustment (manual manipulation of misaligned vertebrae) was its cure (19). The American Chiropractic Association defines chiropractic as “a health care profession that focuses on disorders of the musculoskeletal system and nervous system, and the effects of these disorders on general health” (20). Chiropractors manually adjust the spine to reestablish motion in the vertebral column in order to restore the normal functioning of the nervous system, which serves as the foundation for health and well-being (21).
Chiropractic has engendered controversy from the outset. In the first chiropractic adjustment, Palmer restored the hearing of Harvey Lillard, a janitor in Palmer’s office building who had been deaf for 17 years. Palmer touted chiropractic as a drugless system of healing and as a cure for almost all human ailments (19). Over time, philosophical differences have evolved within the chiropractic profession. A minority of chiropractors adhere to Palmer’s conservative philosophy, relying on deductions from irrefutable doctrines and rejecting scientific reasoning. These practitioners believe that chiropractic adjustment should not be combined with other types of therapy. Most chiropractors, however, seek to combine chiropractic philosophy and scientific principles with a holistic paradigm of health. The mainstream chiropractor, therefore, may incorporate modalities such as nutrition and lifestyle counseling, stress management techniques, acupressure, soft tissue manipulation, and homeopathy.
Chiropractic has developed into the third largest independent health profession in the Western world, after allopathic medicine and dentistry. It is recognized as the largest, most regulated, and best recognized of the CAM professions (22). It is estimated that 30% of all CAM practitioner visits are to chiropractors (2). Many chiropractors, however, view themselves as practicing in the realm of integrated medicine or mainstream medicine and do not view themselves a CAM practitioners (23). Chiropractic training requires 4 years of study, with rigorous educational standards supervised by governmentrecognized accrediting agencies. In the United States, passage of the National Board of Chiropractic Examiners written examination is recognized or required in all 50 states. Most patients go to chiropractors for musculoskeletal problems, with 60% presenting with low back pain and the remainder with head, neck, and extremity symptoms (22).
Massage
Massage as a therapeutic technique dates back thousands of years, with references evident in the writings of ancient Greece (Hippocrates), Egypt, India, and China among other civilizations. Although there are many styles and techniques, massage therapy is based on the principle that the body functions best when arterial supply as well as venous and lymphatic return are unimpeded. Muscle tightness and pain may arise if this flow is hindered. The basic techniques of massage—effleurage, pétrissage, tapotement, friction, and vibration—are directed at the skin, fascia, and muscles and are designed to restore proper fluid dynamics (24). Effleurage is a gliding stroke applied with light to moderate pressure frequently used to start a session or to link between other techniques. Pétrissage massage movements are applied with deeper pressure to lift and compress the underlying fascia and muscle in a kneading motion. Tapotement involves a rhythmic percussion of rapid, repeated taps or blows administered with the edge of the hand, cupped hand, fist, or fingertips. Friction is a technique in which the tips of the fingers or thumbs are used in a circular motion. Vibration involves use of the hands in a light, quivering motion or a mechanical oscillator. Specific styles include Swedish massage, sports massage, acupressure, Shiatsu, trigger point massage, and reflexology.
Massage therapy is becoming increasingly popular in the United States. The 2007 NHIS showed a 66% increase in prevalence of use compared to 2002 estimates (3). There are approximately 1,500 massage therapy schools and training programs in the United States. As of 2010, 43 states had laws regulating massage therapy. Regulations are increasing with states are increasingly requiring that massage therapists meet minimum training requirements at an accredited institution, pass a national exam, complete continuing education requirements, and carry malpractice insurance (25).
Whole Medical Systems
Whole medical systems are complete systems of theory and practice that evolved over time outside of conventional allopathic medicine. Ancient whole medical systems include Ayurveda and TCM. More modern systems that developed over the last several centuries include homeopathy and naturopathy. In the 2007 NHIS, homeopathy ranked as the tenth most commonly used CAM therapy among adults (1.8%) and fifth among children (1.3%) (3).
Ayurveda
Ayurvedic medicine originated during the Vedic period (2000 BC) of ancient India. The word Ayurveda is a compound of two Sanskrit words: Ayus, which means “life” or “life span,” and Veda, which means “knowledge” or “science.” Ayurveda, translated as “the science or wisdom of long life,” is a holistic system of health care that emphasizes wholeness (26). Treatment approaches cover the full range of a patient’s life: mind, body, behavior, environment, and consciousness (27). In Ayurveda medicine, understanding the patient’s mind and body type are essential to diagnosis and treatment. Therapeutic qualities of diet and techniques to balance emotions are emphasized. Ancient Ayurvedic texts contain both an extensive materia medica on the use of medicinal plants and writings on surgery and surgical instruments. One of the eight main disciplines of Ayurveda encompasses otolaryngology-head and neck surgery as well as ophthalmology. Sushruta, a surgeon who practiced and taught along the Ganges River between 800 BC and first century AD described skin flaps, rhinoplasty techniques, and pedicled cheek and forehead flaps for nasal reconstruction (28,29).
Ayurveda is grounded in the metaphysics of five great elements —earth, water, fire, air, and ether—that comprise the universe, including the human body. Three bodily humors, doshas, are derived from the elements and govern the functioning of the body. The doshas are Vata, which governs flow, motion, and homeostatic mechanisms; Pitta, which regulates bodily functions related to heat and metabolism; and Kapha, which controls structure, cohesion, and growth (27). It is believed that a harmony between the three doshas is necessary for optimum health and to maintain the body’s natural state of balance. Ayurveda places great emphasis on strategies to prevent illness. Modalities for the treatment of disease involve rebalancing the patient’s doshas.
Traditional Chinese Medicine
The history of TCM dates back thousands of years, with its origins linked to mythical emperors said to have lived around 2900 to 2600 BC. Shen Nong, or the Devine Farmer, is considered the originator of Chinese herbal medicine. The Devine Farmer’s Materia Medica (Shen Nong Ben Cao Jing) was written around 220 AD and is the earliest known Chinese pharmacopeia with some 365 entries
of medications (30). Huang Di, the Yellow Emperor, is known as the originator of TCM. The Yellow Emperor’s Inner Classic (Huang Di Nei Jing) was compiled around 200 to 100 BC and is considered the fundamental doctrinal source for Chinese medicine.
of medications (30). Huang Di, the Yellow Emperor, is known as the originator of TCM. The Yellow Emperor’s Inner Classic (Huang Di Nei Jing) was compiled around 200 to 100 BC and is considered the fundamental doctrinal source for Chinese medicine.
Chinese medicine is rooted in Taoist philosophy with the fundamental concepts of yin, yang, and qi. Yin and yang convey “the idea of opposing but complementary phenomena that exist in a state of dynamic equilibrium” (31). Yin represents dark, night, cold, female, water, and inside. Yang represents light, day, hot, male, fire, and outside. There is equilibrium between yin and yang in the body. The concept of qi is very broad and can be translated in many ways, but it fundamentally refers to the vital energy or life force throughout the body and the universe. TCM describes 12 bodily organs. These organs are divided into six solid organs (viscera) and six hollow organs (bowels), which are paired in a yin-yang or interior-exterior relationship. Each viscus and bowel has an associated channel that runs through the organ, its paired organ, across the body, and connects with the channel of its related organ. There are 12 regular channels as well as extra channels, divergent channels, and collaterals. Qi is understood to circulate in these channels and can be influenced by accessing 361 specific holes or points that lie along the path of 14 channels (12 regular, 2 extra). Disease can arise when there is an imbalance of yin and yang. Modulating the flow of qi can reestablish balance and restore health and well-being.
Therapeutic modalities in TCM include acupuncture, moxibustion, cupping, bleeding, massage (tui na), qigong, and herbal medicine. Acupuncture and moxibustion are described separately in this chapter. Cupping refers to the use of a heat to induce a vacuum in a small glass or bamboo cup, which is applied as a suction to the skin to bring blood and lymph to the skin surface. Bleeding is performed to drain a channel or to remove heat from the body. Chinese massage refers to manual stimulation of acupressure points. Qigong aims to manipulate qi through breathing, physical activity, and mind awareness. Qigong practices may range from meditative systems to martial arts (31). Contemporary herbal therapy in TCM is comprised of approximately 500 herbs, with about half used frequently in formulations combining 3 to 25 herbs.
Homeopathic Medicine
Homeopathy is a whole medical system that seeks to stimulate the body’s ability to heal itself by giving very small doses of diluted substances. This therapeutic system was developed by the German physician Samuel Hahnemann at the end of the 18th century. Hahnemann articulated two main principles. First, the law of similars (similia similbus curaentur), or “let likes be cured by likes,” states that a disease can be cured by a substance that produces similar symptoms in healthy people. The law of minimum dose states that the lower the dose of the medication, the greater the potency. In a process referred as potentiation, homeopathic remedies are diluted in a stepwise fashion and shaken vigorously between each dilution. Many homeopathic medicines are diluted beyond the molecular threshold of Avogadro’s number with no molecules of the healing substance remaining. Homeopaths believe that the substance leaves its essence or imprint, stimulating the body to heal itself. Hahnemann developed his philosophy after a series of experiments in which he ingested therapeutic doses of chincona bark and experienced symptoms similar to the intermittent fever of malaria. He hypothesized that giving a remedy that mimicked a patient’s symptoms reinforced the body’s ability to heal.
In the United States, homeopathic remedies are prepared according to the guidelines of the Homeopathic Pharmacopeia of the United States and are regulated by the U.S. Food and Drug Administration. Most homeopathic remedies are regulated in the same manner as nonprescription drugs. Since homeopathic products contain minimal to no active ingredients, they do not undergo the same safety and efficacy testing as other over-the-counter drugs. According to the 2007 NHIS, an estimated 3.9 million adults and 900,000 children in the United States used homeopathy in the previous year (3). In many areas of Europe, homeopathy is the most popular form of CAM: 25% of all German physicians use homeopathy, 32% of primary care physicians use it in France, and up to 42% of physicians in the United Kingdom refer patients to homeopaths (32).
Naturopathic Medicine
The foundations of naturopathic medicine may be traced back to Hippocratic practitioners who first used the term vix medicatrix naturae, or “the healing power of nature,” to describe the body’s ability to heal itself. Other philosophical influences include the hydrotherapy movement (use of hot and cold water for health maintenance and disease treatment), nature cure (natural living, vegetarian diet, use of light and air to improve health), Christian Science (religious study, spirituality, and prayer in the treatment of disease), homeopathy, osteopathy, and chiropractic. These eclectic threads were woven into a comprehensive Western system of natural medicine with professional practitioners in the late 19th century by Benedict Lust, who himself had formal training in hydrotherapy, osteopathy, chiropractic, massage, and homeopathy.
Naturopathic medicine emphasizes health promotion, disease prevention, patient education, and patient self-responsibility (33). Naturopathy is not defined by any particular therapy but by the philosophical principles of the practitioner. The concepts of vitalism (life is more than the sum of its biochemical parts) and vix medicatrix naturae (the body has the innate intelligence to heal itself) are fundamental to the practice of naturopathic medicine. In 1989, the American Association of Naturopathic Physicians defined seven core principles of naturopathic medicine, including
The healing power of nature (vis medicatrix naturae)
First do no harm (primum non nocere)
Find the cause (tolle causam)
Treat the whole person
Preventive medicine
Wellness and health promotion
Doctor as teacher (docere)
Naturopathic doctors are trained as family physicians, but may also practice as specialists with additional training. The scope of practice, therefore, may include primary care, botanical medicine, homeopathy, nutritional medicine, acupuncture, Ayurvedic medicine, Chinese herbal medicine, spirituality, counseling, midwifery, and minor surgery.
Other CAM Practices
CAM also includes a wide range of movement therapies and energy techniques. The Feldenkrais method is a system of movement and manipulation aimed at enhancing awareness through movement and reestablishing proper balance and neuromotor patterning. The Trager Approach is a system of movement education in which gentle, rhythmic movement and touch is taught to enhance psychophysical integration and improve physical mobility and performance. Rolfing, also known as structural integration, is a system of soft tissue manipulation and movement education based on the interaction of the human body with earth’s gravity. The Alexander Technique is a method that coordinates breath, posture, and movement. Energy work involves techniques to manipulate the life force or vital energy of the patient. Examples of energy work include qigong, Reiki, therapeutic touch, and healing touch.
CAM FOR THE OTOLARYNGOLOGIST
Prevalence of CAM Use in Otolaryngology Patients
Patients with otolaryngologic complaints commonly use complementary and alternative therapies. In a survey of 1,789 patients presenting to an academic otolaryngology practice in Scotland, 35% had used a CAM treatment in the last 12 months and 18% had used the therapy for an ear, nose, or throat condition (34,35). Less than half of the patients disclosed CAM use to their physicians. The same group found similar responses in their rhinology and head and neck oncology subspecialty clinics (36,37). A study performed at an academic rhinology practice in Canada found that 16% of patients diagnosed with chronic rhinosinusitis had used a CAM therapy for their condition (38). Another recent Canadian study of patients presenting with thyroid nodules to a head and neck oncology practice found that approximately one-half were on CAM oral supplements and one-third of the patients reported using supplements known to affect hemostasis (39). Other investigators in the United States and Europe have found lower prevalence of CAM use in head and neck oncology patients ranging from 6 to 23% (40,41).
Practice Implications
Patients may not inform their physicians regarding CAM use for a number of reasons. They may believe that products are “natural” and thus pose no potential for harm. They may be concerned that the physician might impose judgment for not using mainstream therapy, or they may doubt the physician’s knowledge and ability to provide advice regarding CAM products. Although rare, the use of CAM products has the potential—both theoretic and documented —to negatively impact prescribed medical and surgical treatments. A recent survey of 844 patients presenting to an outpatient clinic revealed that 15% were using herbal medicines and 40% of these had potential herb-drug interactions (42).
Drug-Herb Interactions
Although a complete list of potential herb-drug interactions is beyond the scope of this chapter, some general guidelines and common interactions are discussed. The reader is referred to the resources listed in Table 20.1 to research specific effects and interactions. In the United States, the practitioner should report all suspected adverse events to the United States Food and Drug Administration’s (FDA’s) Medwatch Program (http://www.fda.gov/medwatch) and should encourage patients to inform use of supplements to their pharmacists. When reviewing the literature regarding herbal treatments, one must remember that the evidence is largely anecdotal and based on case reports (43). The preparation of supplements is not regulated by the FDA. There is heterogeneity in both potency and purity
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