The use of complementary and alternative medicine (CAM) has become common in the United States. To maintain effective clinician-patient communication and ensure responsible clinical practice, it is important that clinicians learn some of the theory, practice, and scientific evidence associated with these therapies. This chapter provides an overview of four complementary medicine categories: botanical medicine, nonbotanical dietary supplements, acupuncture, and mind-body medicine.

General Considerations

CAM is defined by the National Institutes of Health (NIH) as a group of diverse health care systems, practices, and products that are not presently considered to be part of conventional medicine.

CAM modalities have been classified by the NIH into five major categories:

1. Biologically based practices include botanicals, dietary supplements, probiotics, vitamins, minerals, certain diets and nutritional practices, and more.

2. Manipulative and body-based practices use manipulation or movement of one or more body parts (eg, massage, chiropractic, Feldenkrais method and other "body work" systems).

3. Mind-body medicine uses a variety of techniques designed to enhance the integration between mind and body, such as biofeedback, meditation, yoga, Tai chi, hypnosis, and guided imagery.

4. Energy medicine involves the use of energy fields, such as magnetic fields or biofields (energy fields that some believe surround and penetrate the human body). Examples include Reiki, external qigong, and therapeutic touch.

5. Whole medical systems are built on complete systems of theory and practice that have evolved apart from—and often earlier than—the conventional medical approach used in the United States. Examples are traditional Chinese medicine, naturopathy, and homeopathy. Systems such as traditional Chinese medicine and Ayurveda incorporate therapies from more than one of the categories listed above.

The Centers for Disease Control and Prevention conducted National Health Interview Surveys (NHIS) in 2002 and 2007. Overall, 23,300 American adults from diverse populations were asked about their use of CAM in the 2007 survey. Thirty-eight percent reported using some form of CAM in the previous 12 months, essentially unchanged from 36% in 2002. The most commonly used CAM therapies were nonvitamin, nonmineral natural products (17.7%), with fish oil, glucosamine, echinacea, flaxseed and ginseng being the most common; deep breathing exercises (12.7%); meditation (9.4%); chiropractic or osteopathic manipulation (8.6%); massage (8.3%); and yoga (6.1%). The most common conditions for which adults used CAM were similar to those seen in most primary care offices: musculoskeletal complaints, such as back, neck, and joint pain. Most people who use CAM combine it with conventional medicine because they perceive the combination to be superior to either alone. People who use CAM 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 CAM use. Interestingly, health care workers may be more likely to personally use CAM therapies than the general population.

Despite the growing numbers of patients seeking CAM, < 40% of alternative therapies used are disclosed to physicians. In one survey of 1559 patients age 50 or older, 70% who used CAM did not tell their physician. Such a lack of communication may be dangerous because some CAM therapies can interact adversely with conventional treatments.

The 2007 NHIS survey also showed that the US public is paying a large amount of money on CAM therapies, an estimated $36 billion in 2007, much of it out-of-pocket. CAM 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.

The Institute of Medicine of the National Academies has recommended that “health profession schools incorporate sufficient information about complementary and alternative medicine (CAM) into the standard curriculum at all levels to enable licensed professionals to competently advise their patients about CAM.” In 2010, a survey of over 1700 medical students from half of all US medical schools found that 77% of respondents agreed to some extent that patients whose doctors know about CAM in addition to conventional medicine benefit more than those whose doctors are only familiar with Western medicine. In addition, 49% of medical student respondents indicated that they have used complementary and alternative treatments for themselves. Also, 61% of the medical students indicated that not enough time was devoted to CAM education in their curriculum.

The leading government agency for research about CAM is the National Center for Complementary and Alternative Medicine (NCCAM) of the NIH. NCCAM’s budget for fiscal year 2011 was $128 million, less than 0.4% of the total NIH budget. Although some CAM modalities are not easily evaluated using randomized control trial methodology, the 2005 Institute of Medicine report recommends that conventional and CAM treatments both be held to similar standards of safety and efficacy.