The Psychosocial Aspects of Complementary and Alternative Medicine

Jacintha S. Cauffield, Pharm.D., GeM Integrative Pharmacotherapy, Inc., Jupiter, Florida

Pharmacotherapy. 2000;20(11) 

Abstract and Introduction

Approximately one in four persons in the United States uses complementary and alternative medicine (CAM). Out-of-pocket costs of CAM rival medical treatment at $21.2-32.7 billion versus $29.3 billion, respectively. Users of CAM tend to have high incomes and high levels of education. They also have medical conditions not easily treated by modern medicine such as chronic pain, poor mental health, human immunodeficiency virus infection, and cancer. The most common therapies are noninvasive (acupuncture, chiropractic, massage), however, consumption of dietary supplements has grown dramatically. Patients often use CAM in addition to modern medicine and are reluctant to discuss CAM with their physicians. Pharmacists' professional approach to science may bias them against CAM therapies. Complementary and alternative medicine use should be included in visit histories and discussed in an objective, nonjudgmental manner to encourage patient disclosure.

"... science must be understood as a social phenomenon, a gutsy, human enterprise, not the work of robots programmed to collect pure information."

Stephen Jay Gould, The Mismeasure of Man ^[1]

To say that the use of complementary and alternative medicine (CAM) experienced a dramatic rise over the past decade is an understatement. From $94 million in 1990, consumers spent an estimated $663 million on medicinal botanicals alone in 1998.^[2] With the passage of the Dietary Supplement Health Education Act (DSHEA) in 1994 and the establishment of the National Center for Complementary and Alternative Medicine (NCCAM) by the National Institutes of Health, the prominence and popularity of CAM has skyrocketed. Much of CAM's prominence is consumer driven. The patient's desire to turn to relatively unproven therapies may seem puzzling when rigorously tested alternatives exist. Thus, an exploration of the psychosocial issues involved with CAM can help to determine which individuals may be predisposed to using CAM, which therapies they use, and their rationale for using them.

Prevalence

Between 1990 and 1997, the number of consumers using CAM therapies rose significantly, from 33.8% to 42.1%.^[3] Some (46.3%) saw a CAM practitioner, but the remaining 53.7% were unsupervised in their use of CAM. During that same time period, the number of people who sought advice from both physicians and practitioners of CAM rose from 8.3% to 13.7%. Only 38.5% reported CAM use to their physician, even though 96% had seen their doctor within the past year. Even more concerning, 58.3% paid out-of-pocket for CAM services. Total estimated expenses were $21.2-32.7 billion, comparable with the estimated $29.3 billion out-of-pocket expenses for all United States physician visits.^[3,4] In an age of rising medical costs and customer concerns regarding cost, these people see enough value in CAM therapies to use their own money to obtain them. Are there characteristics that predispose individuals to seek CAM therapies? Identifying these factors may aid in preventing mishaps from mixing CAM and conventional medical treatment.

In a 1997 study, subjects using CAM therapies were more likely to be college educated (50.6%), aged 35-49 (50.1%), of Caucasian descent (77%), have incomes greater than $50,000 (48.1%), and live in the western United States (50.1%).^[4] The most common medical condition reported among the surveyed subjects was back problems at 24% (Figure 1). Of interest, 47.6% of these patients sought CAM, versus subjects with high blood pressure (11%). Neck problems were associated with the highest use of CAM (57% of patients). Subjects with other chronic pain conditions, including arthritis and headache, and mental health conditions, including insomnia, depression, and anxiety, were also high users of CAM therapies.^[3,4] These disorders are not easily treated with conventional medical therapies. They also involve complex lifestyle issues, including the socially imposed stigmata associated with mental illness, disability, and/or the treatment with controlled substances. Patients experiencing chronic pain often do not obtain relief from drugs or other medical treatment. Similarly, medicine offers numerous modalities for treating depression and anxiety, but patients may be reluctant to seek medical help, may lack insight into their condition, or may prefer to self-treat. Indeed, in a survey of 100 patients with panic disorder or agoraphobia, as defined by Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R) criteria, 32% used herbs. Ironically, herbs were less satisfactory to these patients than antidepressants, benzodiazepines, or psychotherapy.^[5]

A survey of 16,048 women revealed a prevalence of CAM of 8.3%.^[6] As in the study mentioned earlier,^[4] the highest quartile of use was associated with high levels of education, Caucasian background, and a high use of preventive services. Women using CAM also reported 7.9 physician visits/year, versus 5.4 visits by the lowest quartile. Women in the highest quartile demonstrated a great degree of debility, poor mental health, and decreased ability to perform activities of daily life by objective measures. Only 19.7% of women using CAM reported the activity to their physicians. Of interest, 8.8% reported that a physician referred them to a practitioner of CAM.

Patients infected with the human immunodeficiency virus (HIV) are also high users of CAM. One hundred eighty patients infected with HIV reported an annual average of 12 visits to a CAM practitioner, versus 7 visits to their physician or nurse practitioner.^[7] They most commonly visited massage therapists, or acupuncturists or acupressurists, and only 64% reported these services to their physicians. They paid an average of $939/year for out-of-pocket expenditures for these services, on top of the estimated $1801/year for medical expenses. Ominously, 16% of these patients stopped traditional drug therapy.^[7]

Between 7 and 64% of patients with cancer use CAM therapies, with an average of 31.4%.^[8] Vitamins, prayer or religious practices, and herbs dominate the therapies chosen by 42.6% of men with prostate cancer. Probability of use was independent of treatment modality, but only 17-30% reported the use to their physicians.

Similarly, 38.8% of 480 women with stage I or II breast cancer participated in some form of CAM prior to surgery, whereas only 28.8% did after surgery.^[9] Use of healing and psychological therapies was highest before surgery and tapered throughout the first year. After 12 months, approximately 50% of women reported new use of both psychological and healing modalities, whereas 45% reported continued use. Therapy with CAM was not associated with cancer staging or method of treatment.

As mentioned previously, patients with arthritis have a high rate of CAM use. A survey of patients in a rheumatology clinic revealed a 63% CAM utilization rate, with an average of 2.5 therapies/patient.^[10] Patients diagnosed with rheumatoid arthritis were more likely to use CAM (38%) compared with those who had osteoarthritis (23%) and fibromyalgia (19%). Half of the patients who tried dietary supplements or vitamins reported some benefit. Only half told their physicians about their CAM therapies.

The CAM modalities that patients choose appear to match the medical conditions reported. In a 1997 survey, relaxation techniques, which commonly are used for patients with chronic pain and/or mental conditions, were the most common alternative therapy (Figure 2).^[4] Other modalities, such as massage, chiropractic and acupuncture, also are used for chronic pain. Of interest, subjects are turning increasingly to dietary supplements as treatment modalities. Herbal therapies were the second most common therapy, with 12.1% of those surveyed reporting use in 1997, up significantly from 2.5% in 1990.^[4,5] Similar therapies, megavitamins, and folklore remedies, are also popular. With potential drug interactions and unexpected adverse effects, dietary supplements should be a routine part of drug histories.

The top 10 selling herbs in 1997 reflect the medical conditions reported in the previously mentioned survey.^[4] Gingko biloba was second only to echinacea in sales.^[2] Although this seems unrelated to the medical conditions discussed above, gingko increasingly is taken by patients to treat medical conditions other than dementia. These include allergies, intermittent claudication, and depression.^[11] Other top sellers such as St. John's wort, kava kava, and valerian are taken by patients to treat depression, anxiety, and insomnia, respectively.^[11]

In the survey of patients with HIV, 67.6% reported trying dietary supplements, mostly to treat weight loss, nausea, and vomiting, or for their antiviral and immunostimulating properties, with an 81% rate of satisfaction.^[7] In comparison, 45% saw a CAM practitioner, mostly for pain and neuropathy or relief of stress and depression, with 65.5% benefiting. To treat weight loss, nausea and vomiting, 23.9% reported using marijuana, with an 87% satisfaction rating.

Although patients with the specific demographics and medical conditions discussed earlier seem more predisposed to CAM, even healthy people seek these therapies. In the survey of rheumatology clinic patients, the most common reasons for CAM were to alleviate pain and ease their rheumatic condition.^[10] Fifty percent of respondents reported turning to CAM because they perceived their drugs as ineffective. When 113 patients at a family practice were interviewed, the top reason to seek CAM therapies was that they believed they would work.^[12] Those who chose to reveal use stated that their physicians accepted their use and respected the patient's desire to have more control over their health.

One popular hypothesis has been that patients who seek CAM were dissatisfied with conventional treatments, desired more control or autonomy over decisions involving their health, or saw CAM as more compatible with their world views and beliefs. Surveys designed to test these hypotheses failed to document the first two. In one survey, only 4.4% of subjects relied primarily on CAM.^[13] Links with cultural beliefs were found -- specifically, a commitment to environmentalism and feminism, and an interest in spirituality and personal growth psychology. A holistic health philosophy, a strong internal locus of control and transformational life experiences also were associated with CAM.^[13-15] Like the 1997 survey,^[4] these patients had a high prevalence of back problems, chronic pain, or anxiety.^[13]

Individual cultural upbringing and ethnicity also define CAM use. These issues were well studied in the Navajo people. Community and family are very important to them, and they see these bonds between community and family as a form of preventive medicine. They have a holistic health concept called "walking in beauty." To a Navajo, beauty refers to the balance that exists among all things and the ability to live in harmony with oneself and the world. A person who respects and honors these relationships is considered to be "walking in beauty." When a Navajo becomes sick, he is considered to have an imbalance with his relationships. He must visit a medicine man to be restored to beauty.^[16]

In a cross-sectional interview of 300 Navajo patients at an Indian Health Service (IHS) hospital, 62% had gone to native healers and 39% visited them regularly.^[17] The factor associated with the least amount of visits was Pentecostal faith (p< 0.001). The Navajo were more likely to rely on IHS medical therapy, either alone or with native healers, for physical conditions such as diabetes mellitus, arthritis, abdominal pain, depression, and anxiety. They sought native healers exclusively for traditional issues (family problems, blessings, "bad luck" or "sickness"). Ironically, cost was the biggest barrier to seeking a native healer. Native healer costs are approximately 21% of the average Navajo income, whereas care at an IHS clinic or hospital is free.

These studies raise some serious issues as to the rift between Native American cultural values and access to native healers. In areas where native healers are available, Native Americans frequent them. Income, not belief systems, prohibits interaction.^[17,18] Some IHS facilities have addressed this gap by incorporating sweat lodges, or similar spaces, into their facilities and employing native healers.

Patient Satisfaction and Communication with their Physicians

Are patients satisfied with the CAM therapies? As mentioned previously, patients with agoraphobia or panic disorder reported more benefit from medical therapies than herbs. In a survey of 1584 South Carolinian adults, approximately 68% perceived their therapy to be effective or very effective, depending on the specific modality.^[19] Those working with spiritual healers were most likely to report satisfaction (79%), whereas those participating in weight loss programs reported the least satisfaction (44.9%). People involved in herbal medicines, folklore remedies, vitamins, and homeopathy reported a 62% satisfaction rate.

In a survey of over 46,000 patients with 35% using CAM, 23% of those trying herbs and dietary supplements reported feeling much better.^[19] This rate was comparable with levels of satisfaction found with both mind-body techniques and over-the-counter drugs, but was inferior to satisfaction with prescription drugs (50%). Satisfaction levels varied widely depending on medical condition and therapy. Patients with some of the difficult-to-manage medical conditions, including back pain, neck pain, and fibromyalgia, reported CAM therapies to be comparable with standard medical care.

Why don't patients tell their health care providers that they are using CAM? In the South Carolina survey, physicians who recommended CAM therapies were more likely to be told about use from their patients.^[20] Patients were least likely to report hypnosis or biofeedback (12.1%), or healing therapies (21.3%). Only 25.8% reported using herbal medicine and similar preparations to their physicians, increasing their risk for adverse reactions.

In another survey, patients cited limitations and narrow-mindedness on the part of their physicians as a reason for not revealing use.^[14] In a survey of women with breast cancer, 55-85% partook in CAM therapies but did not divulge use to their physicians due to assumed disinterest.^[21] Other reasons included anticipated negative physician response, perceived physician unwillingness and inability to help, that disclosure was not relevant, that healing strategies viewed as disparate, and that physician-facilitated discussion would occur.

How do physicians perceive CAM? In the study of over 46,000 patients using CAM, 60% eventually reported CAM use to their physicians.^[19] According to these patients, 55% of physicians expressed approval, with 40% expressing neutrality, and 5% expressing disapproval. In the survey of South Carolina adults, physicians were most likely to recommend biofeedback or hypnosis (39.3%), self-help groups (33.4%), or lifestyle and dietary changes (33.2%).^[20] Personal therapies, including herbal medicine, were recommended by 15.2% of physicians. In another survey, approximately 50% believed in the efficacy of acupuncture (51%), chiropractic (53%), and/or massage (48%).^[22] Only 13% believed in using herbal therapies. Approximately 40% had referred patients to either an acupuncturist or chiropractic practitioner, whereas 20% referred patients for massage therapy.

Conclusions

Although no definite conclusions can be drawn from population data, a few patterns emerge. Patients with medical conditions that are difficult to treat or do not have easy or positive answers by conventional medicine standards seem predisposed to CAM. Patients who use CAM have high incomes and levels of education, and pay out of pocket for these services. Although dietary supplements are popular with patients, many of the most commonly used therapies are noninvasive. Some therapies, such as lifestyle modification, behavior modification, and relaxation techniques, are a routine part of treatment plans. Others, such as acupuncture, chiropractic, and massage, are gaining wide acceptance from the medical community.

Patients often use CAM with conventional medicine, although patients remain reluctant to tell their providers, often because they fear their physicians will not be receptive. More recent data suggest that physicians are more open about discussing CAM than patients perceive.^[19] With the recent accumulation of herb-drug interaction data, such as St. John's wort with cytochrome P450 3A4,^[23] discussion of CAM in a tactful and nonjudgmental way is becoming even more important.

Even with the increased focus on evidence-based medicine, clinical practice is likely to retain some artistic elements. Patients present as whole people. In addition to their physical body, they have a belief system, social background, and hopes and fears that will color their choices and responses to therapy. Despite the emphasis on objectivity, practitioners bring a similar background into their practice style. Although professional training places a great deal of education on the scientific method, practitioners are humans first. By their very nature, humans are incapable of being entirely objective. Indeed, a review of research on human intelligence with respect to ethnic background reveals how deeply the societal prejudices of the time biased study results.^[1]

A recurring model of scientific knowledge posits that rather than subtly creeping ahead as data accumulates, science makes quantum leaps. Quiet interludes are punctuated by intellectually violent revolutions that lead to dramatic paradigm shifts. Witness Copernicus and the heliocentric universe, Pasteur and the germ theory, Watson and Crick with the DNA double helix. None of these ideas was openly accepted when first presented, but all have dramatically enhanced scientific advancement.^[24] Although it is too soon to tell, complementary medicine may well become part of a paradigm shift. Not half a century ago, isolation of chemicals from natural sources was a challenge. There were no good methods for testing plants or animal materials for potential medicines, and so discounting folkloric use was relatively easy. The situation is now different. Where would patients with congestive heart failure be today if a creative individual had not thought to examine snake venom and develop captopril?

Despite the role that CAM takes in future health care, practitioners must be able to discern their own individual values and biases from objective, evidence-based data. This awareness will help guide patients to safe, comprehensive regimens as new therapies are introduced.

"... science's potential as an instrument for identifying the cultural constraints [imposed] upon it cannot be fully realized until scientists give up the twin myths of objectivity and inexorable march toward truth."

Stephen Jay Gould, The Mismeasure of Man ^[1]

Reprint Address

Address reprint requests to Jacintha S. Cauffield, Pharm.D., GeM Integrative Pharmacotherapy, Inc., 11200 164th Court, North Jupiter, FL 33478.

Pharmacotherapy. 2000;20(11) © 2000 Pharmacotherapy Publications
Copyright © 1999, Pharmacotherapy Publications, Inc., All rights reserved.

Cite this: The Psychosocial Aspects of Complementary and Alternative Medicine - Medscape - Nov 01, 2000.