IM16 - Integrative medicine contextual unit

Rationale

The practice of integrative medicine refers to the blending of conventional and evidence-based natural and complementary medicines and/or therapies with lifestyle interventions to deliver holistic, patient-centred care. The overarching aim of integrative medicine is to use the most appropriate, safe, ethical and evidence-based modality(ies) available, with a particular focus on prevention and lifestyle interventions. This practice is informed by evidence and patient preference, and enables a broader range of therapeutic options and disciplines to be made available for patients to achieve optimal clinical outcomes.¹

Previous surveys of Australian general practitioners (GPs) have found that many incorporate aspects of integrative medicine, including prescribing or recommending complementary medicines, into their practise, and that many have identified an urgent need for high-quality complementary medicine information resources to be provided to assist their knowledge and to help facilitate communication with patients.^2–4

Incorporating the use of evidence-based, safe and ethical integrative therapies aims to:

• provide a greater range of therapeutic options to patients to relieve symptoms, offer another trial of treatment option for conditions for which conventional medicine does not currently have exhaustive options to treat, prevent disease, and enhance physical and psychological health
• individualise the approach to any particular patient or clinical situation, using the best available modalities in conjunction with informed patient choice
• assist patients to make safe and balanced decisions regarding the use of integrative therapy
• avoid potentially harmful interactions between integrative and conventional therapies.

Integrative practice involves more than adding some complementary medicine knowledge to the ‘kit bag’ of the GP; it does not reject or compete with conventional healthcare and overlaps significantly with what is currently widely accepted as quality general practice. Integrative medicine training should therefore not be viewed as a separate aspect of general practice. Complementary medicine refers to therapies and medicines that are not conventionally used by doctors, but which may complement medical management and thus be successfully integrated into medical practice.

A significant driver for the incorporation of integrative medicine into general practice education has been the rising community interest in integrative therapies. The evidence demonstrates that the majority of patients in Australia regularly use or have used complementary medicines and/or integrative therapies as well as conventional medicines and often do not discuss this with their GP.^5–8 In 2011–12, 29% of Australians reported taking at least one dietary supplement on the day prior to an interview by the Australian Bureau of Statistics.⁹

Many complementary therapies are now available for purchase online, which can be a concern as most of these sites are not within the jurisdiction of the Therapeutic Goods Administration.¹⁰ There are potential risks of side effects, interactions and cumulative effects when conventional and integrative therapies are taken together. It is important for GPs to ask patients about their use of complementary therapies and to be aware of the evidence basis, or lack thereof. GPs should also have the knowledge to provide patients with balanced information about potential benefits and risks in order to enable informed decision making.

The various integrative medicine modalities defined below should be viewed on their own individual merits, and not grouped together under the term ‘complementary and alternative medicine’ (CAM). The reason for this recommendation is that these modalities vary markedly in terms of definition, philosophy, principles, level of scientific evidence, risks, clinical uses and potential benefits, and in the level of skill required by the health practitioner to incorporate them into clinical practice. GPs will train and integrate the modalities into clinical work, which matches their own practice style, sociocultural and philosophical values. Examples of integrative medicine modalities include:

• mind–body medicine interventions – use a range of techniques designed to enhance the mind’s capacity to affect bodily functions and symptoms, eg mindfulness meditation, biofeedback, cognitive behavioural therapy and hypnotherapy
• biologically-based therapies – include nutritional supplements, herbs, spices and dietary supplements
• nutritional medicine – includes the use of nutraceuticals such as amino acids, fatty acids (eg fish oils), vitamins, minerals (eg iron, magnesium, calcium, iodine), and whole-food powders/juices/functional foods (eg spirulina, aloe vera, slippery elm, bitter melon), usually taken in the short-term to assist recovery or to correct nutritional deficiency
• herbal or spice substances – using all or part of a plant (root, leaves, stem, fruit) or extract (active ingredient) for medicinal purposes. Usually taken in various forms (dried, liquid, tea, powder, capsules) for the treatment or management of a condition. Medicinal spices include turmeric and cinnamon. Medicinal herbs include St John’s wort, chasteberry and evening primrose oil
• manipulative and body-based methods – include musculoskeletal therapies, manipulation, trigger point therapy, the Feldenkrais method, the Alexander technique, postural advice, musculoskeletal medicine (eg manipulation, chiropractic and osteopathic), massage, yoga, tai chi and qigong
• medical acupuncture – the process of stimulation – through the skin – of one or several points on the body to treat various medical disorders. Needles, laser moxibustion and other stimuli may be used to elicit a stimulus to create a therapeutic response. Acupuncture must be performed by a suitably qualified practitioner
• environmental medicine – includes advice on reducing or avoiding exposure to allergens, pollutants (air, noise, water or food-borne sources) and chemicals (occupational and home), promoting a clean environment (ie air, water, foods), and appropriate (more or less) sun exposure.

Other areas of alternative medicine not commonly practised by GPs, which are not in the scope of this curriculum, are included here because it is important for health professionals to have a basic understanding of these as patients commonly use them for treatment of conditions and may decline approaches with a stronger evidence base. GPs are perfectly positioned to provide counselling to patients in this situation about the potential benefits and risks of different approaches to treatment. Examples of such therapies include:

• traditional healing systems – are built upon complete systems of theory and practice such as naturopathic medicine and traditional Chinese medicine, including acupuncture and Ayurvedic medicine
• homeopathy – refers to the use of a diluted preparation manufactured from a mother substance, which is formulated for use on the principle that it is capable of producing – in a healthy person – symptoms similar to those it is administered to alleviate.

As noted previously, the use of integrative therapies is not free of risk. Decisions about the use of these therapies should be based on an assessment that finds the potential benefits outweigh the potential risks. These risks are varied and are not restricted to the direct effects of the therapy, but include denying and not informing the patient of appropriate conventional care and the potentially significant financial costs associated with its use.^11,12

The treatment offered should:

• not delay or preclude any other necessary or more effective evidence-based treatment (eg the need for surgery or antibiotics in emergency situations)
• have a favourable risk:benefit ratio compared to other treatments for the same condition or for no treatment
• be based on the best available evidence to support its effectiveness
• be based on a reasonable expectation that it will result in a favourable patient outcome, including preventive practices
• be provided for a trial period, with observation undertaken for a therapeutic clinical response during this time. If there are no clinical benefits obtained compared with the risk of trialling the therapy, the treatment should then be reviewed and abandoned.

Integrative medicine embraces and encourages a holistic approach to practice, incorporating patient involvement in self-care, prevention and lifestyle interventions. Integrative medicine should therefore be a routine part of mainstream general practice. GPs need to be aware of the growing scientific evidence and/or lack of evidence for many of these therapies. Their broad-based scientific and generalist training and regular contact with the community mean they are ideally placed to assist patients in making choices in regards to integrative medicine.