e4-01: Overview: Integrative Medicine

According to 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 because 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, and 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 so that it 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, clinicians should learn some theory, practice, and scientific evidence associated with these therapies. This chapter summarizes 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.

Studies from the National Health Interview Survey (NHIS) conducted by the CDC report that approximately one-third of Americans used some form of CIT in the previous 12 months. This proportion has stayed consistent over 15 years. In addition, studies using the National Health and Nutrition Examination Survey (NHANES)—another CDC-administered survey—have found the overall use of dietary supplements to be high (52% of the US population reporting any use in the previous 12 months), with large increases in vitamin D and fish oil. Prior NHIS surveys have noted increases in the use of yoga, meditation, and chiropractic care.

Most people who use CIT combine it with conventional medicine because they perceive the combination to be superior to either alone. Most choose therapies from a single category (eg, mind-body medicine versus HDS versus manual therapies), but 25% use two or more therapies. People who use CIT are more likely to be female, middle-aged, have a higher level of education, and have more than one medical condition. Dissatisfaction with conventional medicine has not 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 a 2019 systematic review, only 33% of adults disclosed use of CIT to their health care provider. The most cited reasons for disclosure were that the provider asked about CIT use, the patient expected the provider to be supportive of their CIT use, or the patient believed disclosure was important for safety. The most common reason cited for nondisclosure was fear of the provider's disapproval, followed by their clinician not asking about complementary medicine use.

The US public spends an estimated $34 billion annually on CIT, 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 health care expenditures. A growing number of studies suggest that integrative care may be cost-effective and cost-saving, resulting in significant decreases in health care utilization.