e4-01: Overview: Integrative Medicine

According the National Center for Complementary and Integrative Health, integrative medicine brings together complementary therapies (eg, supplements, natural products, and mind-body therapies) into mainstream health care. It is evidence-based and patient-centered in that it considers the clinician's relationship with the patient as the central therapeutic element. It is comprehensive in its approach, assessing the patient's mind, body, and spirit as well as the social, community, and environmental dimensions of health. It strongly emphasizes foundational health practices such as nutrition, exercise, sleep, and stress management. In addition, it recognizes that the human being has a powerful, innate capacity for healing. Finally, it incorporates complementary modalities when clinically indicated, in a way that is safe and synergistic with conventional therapies.

Complementary and integrative therapies (CIT) can be divided into five categories:

1. Biologically based therapies (eg, use of natural products such as fish oil, probiotics, botanical medicines)

2. Mind-body medicine (eg, biofeedback, meditation, hypnosis, guided imagery)

3. Manual medicine (eg, osteopathy, chiropractic, massage therapy)

4. Energy medicine (eg, reiki, therapeutic touch)

5. Whole systems (eg, traditional Chinese medicine, Ayurveda, homeopathy)

Some of these therapies, especially some of the whole systems, are several thousand years old, and as complete systems, they include elements from all other categories. For example, traditional Chinese medicine uses acupuncture (which might be energy medicine or manual medicine), botanical medicines (biologically based therapies), tui na (manual medicine), and qigong (mind-body medicine).

The use of CIT is common in the United States and around the world. To maintain effective patient-provider communication and ensure responsible clinical practice, it is important that clinicians learn some theory, practice, and scientific evidence associated with these therapies. This chapter provides an overview of three CIT modalities: herbal and dietary supplements (HDS), acupuncture, and mind-body medicine, as they represent the commonly used therapies studied in research and used in clinical practice.

The National Health Interview Survey (NHIS) conducted by the Centers for Disease Control and Prevention in 2012 included questions on the use of CIT. Results showed that 33.2% of Americans reported using some form of CIT in the previous 12 months. This percentage has stayed very consistent over 10 years. The most commonly used CIT were nonvitamin, nonmineral natural products (17.7%), with fish oil, glucosamine and/or chondroitin, and probiotics being the most common. Compared to the 2012 NHIS survey, initial reports from the 2017 NHIS survey noted that there were increases in the use of yoga (from 9.5% to 14.3%), meditation (4.1% to 14.2%), and chiropractic care (9.1% to 10.3%). Children's use of yoga increased significantly from 3.1% in 2012 to 8.4% in 2017; the use of meditation in children also increased significantly from 0.6% in 2012 to 5.4% in 2017. The use of chiropractic care in children appears to be steady at 3.5%.

Most people who use CIT combine it with conventional medicine because they perceive the combination to be superior to either alone. Most people choose therapies from a single category (eg, mind-body medicine versus HDS versus manual therapies), but 25% of people use therapies from two or more categories. People who use CIT are more often female, are middle-aged, have more education, and have more than one medical condition. Dissatisfaction with conventional medicine has not previously been found to predict greater CIT use. Interestingly, health care workers may be more likely to personally use complementary medicine therapies than the general population.

According to the 2012 NHIS, only 63.2% of adults disclosed use of CIT to their health care provider. Patients who perceive benefits, engage in their health care, have perceived positive relationships with their practitioners, and have more control and autonomy over their health are more likely to disclose. The most common reason patients cite for nondisclosure is that their clinician did not ask about complementary medicine use.

The US public spends significant amounts of money on CIT: an estimated $34 billion annually, with much of it out-of-pocket. It accounts for approximately 1.5% of total health care expenditures and 11.2% of total out-of-pocket expenditures on health care in the United States. A growing number of studies suggest that integrative care may be cost effective and cost saving, with significant decreases in health care utilization.