Garlic to Ginseng Challenging Alternative Medicine Queries @ Your Library Sally M. Patrick, M.L.S. Project Director Utah Consumer Health Information Initiative Alice Weber, M.L.S., RN Acquisitions Librarian Spencer S. Eccles Health Sciences Library University of Utah Utah Library Association Annual Conference May 6, 2004

Goals for Today Introductions & overview of Eccles Library services & resources Brief history of Complementary & Alternative Medicine (CAM) Realize the need to promote an evidence based approach to educating consumers about CAM Provide exposure to Evidence-based resources in CAM Introductions: Sally – Public librarian teaching consumer health information Alice-I have been a Registered Nurse for over 30 years & worked in many different areas of the country and of nursing, including a chiropractor’s office. As a librarian and a nurse, I recognize that everyone needs health information, and I appreciate that fact that not all health information available is good, reliable information. Last fall we both went to an MLA class emphasizing the evidence-based approach to CAM. When we say evidence-based, we mean those therapies that have had scientific, clinical testing with proven results. We will share some of the great resources available through Eccles Library. We will discuss the history and context of CAM, and then talk about the most important aspect for you to share with your patrons—the importance of educating consumers about evidence-based health information. And we will provide exposure to some of these evidence-based resources.

History Ayurveda – 1500 BC to AD 500 Acupuncture – 5,000 years old Traditional Chinese Medicine (TCM) – 2,000 years old Homeopathy – 1790s Allopathic Medicine To give you a little background-- In the United States we seem to divide medicine into “Western” and “non-Western” categories. The most common non-western medicines typically are thought of as Chinese medicine and Ayurveda (which originated in India). The U.S. Medical establishment has typically considered anything not originating here to be not mainstream—alternative-- and therefore suspect. However, there is a movement that says there is no “alternative” medicine, only unproven medicine for which scientific evidence is lacking. But lack of evidence can be a big deal! So we now have Evidence-Based resources. Non-western medicines have been around for many centuries and are well-accepted in their cultures and societies, but until recently have not been well-known in the United States. (A bibliography of all this information is in your packet.) Ayurveda is one of the oldest systems of medicine on earth. Written texts show that ayurvedic medicine was practiced primarily from about 1500 BC to AD 500 and was incredibly advanced, with detailed knowledge of pediatrics, psychiatry, surgery, geriatrics, toxicology, general medicine and other specialties. Acupuncture is over 5,000 years old. And though we think of it as Chinese, it was not just practiced in China. The Egyptians talked about vessels that resembled the 12 meridians in 1550 B.C. in their medical treatises called the Papyrus Ebera. Traditional Chinese Medicine (TCM) has a recorded history dating back over 2,000 years. A number of medical treatises were found, written on silk banners and bamboo slips, dating from 221 BC to 220 AD, and represent the oldest surviving Chinese medical literature. In ancient China the doctor was paid as long as the patient was healthy. The doctor stopped getting paid when the patient became sick. The doctor had failed to help the patient maintain health. Samuel Hahnemann lived from 1755-1843. He was the German physician who first described homoeopathy, began his pioneering experiments in the 1790s. Homeopaths treat disease using very low-dose preparations administered according to the principle that "like should be cured with like." Practitioners select a drug that would, if given to a healthy volunteer, cause the presenting symptoms of the patient. For example, the homeopathic remedy Allium cepa is derived from the common onion. Contact with raw onions typically causes lacrimation (tearing), stinging and irritation around the eyes and nose, and clear nasal discharge. Allium cepa might be prescribed to patients with hay fever, especially if both nose and eyes are affected. Allopathy is a method of treating disease with remedies that produce effects different from those caused by the disease itself. It is a term invented by Hahnemann to designate the ordinary practice of medicine, as opposed to homeopathy. It is generally considered typical “Western” medicine. Allopathic medicine works superbly for acute illness and trauma. It does not always work as well for the chronic illnesses suffered by 69% of our population. In January 1993, an article entitled, “Unconventional Medicine in the United States: Prevalence, Costs and Patterns of Use” was published in the New England Journal of Medicine by David M. Eisenberg and colleagues. This study showed that much more growth had occurred in the public’s use of alternative health care than the medical establishment realized. For example, in 1990 Americans made an estimated 435 million visits to alternative practitioners, compared with 388 million visits to primary care physicians. $13.7 billion was spent on alternative treatments, $10.3 billion of it out-of-pocket; whereas $12.8 billion was spent out-of-pocket for all U.S. hospitalizations. (Be careful of statistics—much CAM is not covered by insurance, hence it is all out-of-pocket.) Nevertheless, the study seems to imply that Americans made more visits to alternative practitioners to conventional physicians; spent more money in the aggregate for these alternative treatments than was paid for all U.S. hospitalizations; and paid three-quarters of these costs out of their own pockets. Subsequent studies in 1994, 1998, and 1999 confirmed this trend. Moreover, visits to alternative practitioners increased from 427 million in 1990 to 629 million in 1997. Complementary and alternative medicine is big business.

History in the U.S. 1991- $2 million to NIH 1993 – Office of Alternative Medicine (OAM) 1998 – NCCAM established 2001 – CAM on PubMed 2002 – NCCAM’s first Clinical Trial This has impacted health care and health care legislation in the U.S. In October 1991 the U.S. Congress passed legislation that provided $2 million in funding to establish an Office within the National Institutes of Health to investigate and evaluate promising unconventional medical practices. And the term “alternative medicine” was officially adopted by congress in 1992. In June 1993 the Office of Alternative Medicine (OAM) was formally established to facilitate, study, and evaluate complementary and alternative medical practices and to disseminate the resulting information to the public. In 1998 Congress officially adopted the term “Complementary and Alternative Medicine (CAM), and in October of that year Congress established the National Center for Complementary and Alternative Medicine (NCCAM). This elevated the status of the OAM to a National Institutes of Health Center. In February 2001 NCCAM and the National Library of Medicine launched CAM on PubMed, on internet source of research-based information on Complementary and Alternative Medicine. (And lest we forget how new all of this is) In April 2002 the results of NCCAM's first clinical trial, of St. John's wort for major depression, were released, giving national impetus to an evidence-based approach to CAM. As we see, CAM is big business, and naturally some people are just out to make a buck, not necessarily to help other people. It is very important to be sure that health information is credible and evidence-based. (The books on display range from popular to evidence-based, to give some idea of the many things available. Just a caveat here, some items like the PDRs were donated to Eccles Library, but were not added to the collection because they have been superceded by newer editions, and please be aware that PDRs are put out by drug companies and therefore bias cannot be excluded.)

The Reference Interview… Things to Consider Provide complete and authoritative health information not medical advice or interpretations When in doubt, always refer back to practitioner Teach critical evaluation of Internet resources Anxiety – be sensitive and respect privacy Sally -- This could be a whole class! Special considerations when dealing with health information.

Evaluating Consumer Health Information Resources MedlinePlus Guide to Healthy Web Surfing Consider the source Focus on quality Be a cyber-skeptic Look for the evidence Check for currency Beware of bias Protect your privacy Consult with a health professional From MedlinePlus page on Evaluating Health Information Be critical of all information!-especially CAM. Evidence Based! Be a cyber-Skeptic; commercial $links; difference .net vs. .com etc. Sally Another way of evaluating medical resources (NCCAM) 10 Things To Know About Evaluating Medical Resources on the Web-NCCAM The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading. This short guide contains important questions you should consider as you look for health information online. Answering these questions when you visit a new site will help you evaluate the information you find. On this page Who runs this site? Who pays for the site? What is the purpose of the site? Where does the information come from? What is the basis of the information? How is the information selected? How current is the information? How does the site choose links to other sites? What information about you does the site collect, and why? How does the site manage interactions with visitors?

NCCAM is the Federal Government's lead agency for scientific research on complementary and alternative medicine. This is a screen shot of their home page. NCCAM's mission is to explore complementary and alternative healing practices in the context of rigorous science, to train CAM researchers, and to inform the public and health professionals about the results of CAM research studies.

Complementary and alternative medicine, as defined by NCCAM, is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether they are safe and whether they work for the diseases or medical conditions for which they are used. (live link one step in) As you can see on this web page, NCCAM helps introduce consumers to the terms frequently used. Are complementary medicine and alternative medicine different from each other? What is integrative medicine? What are the major types of CAM? We’ll try to briefly share the answers to these questions.

CAM Definitions Complementary Alternative Integrative Medicine Used together with conventional medicine. Alternative Used in place of conventional medicine. Integrative Medicine Combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness. Complementary medicine is non-mainstream treatments used together with conventional therapies. An example of a complementary therapy is using aromatherapy to help lessen a patient's discomfort following surgery. Alternative medicine is considered to be unproven therapies used instead of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor. Integrative medicine combines those complementary therapies for which there is some high-quality scientific evidence and conventional medicine under the recommendation of a conventional physician.

CAM Categories Alternative Medical Systems Mind-Body Interventions Biologically Based Therapies Manipulative and Body-based Methods Energy Therapies Biofield Therapies Bioelectromagnetic-based Therapies NCCAM categories include: Alternative medical systems which are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. W have discussed some examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine; and some examples of systems that have developed in non-Western cultures including traditional Chinese medicine and Ayurveda. Mind-body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioral therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, dance, or bibliotherapy. Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements, herbal products, and the use of other so-called "natural" but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer). Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage. Energy therapies involve the use of energy fields. They are of two types: Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating current or direct current fields. We’re going to do some example searches including: Ginseng, Chiropractic, Reiki,

Online Resources just for starters… Eccles Health Sciences Library http://medlib.med.utah.edu/ Librarians’ Index to the Internet Utah Public Pioneer -http://pioneer.utah.gov/ Utah Consumer Health Information Network http://uchin.med.utah.edu/ As Alice noted in her history, the very first clinical trial on NCCAM was not until 2002-SO MOST CAM RESOURCES AND REMEDIES HAVE NOT YET BEEN TESTED-SO THERE IS MUCH MORE EVIDENC=BASED RESEARCH TO BE DONE. NO WORRIES!-WHAT HAS BEEN DONE INTERSECTS IN YOUR WEB BROWSING-SO IF YOU DO NOT FIND A RESOURCE ALONG ONE PATH, YOU WILL EVENTUALLY FIND IT BY ANOTHER SEARCH STRATEGY. So…I will show you paths but just know you will come upon the good sites. Run through each web link and show progression to get to CAM stuff (need live links running) htttp://medlib.med.utah.edu> Subject Links>Consumer Health>More Consumer Health>Alternative Medicine > Nutrition & Food Nutrition & Foods/NIH Office of Dietary Supplements>Health Information>More Resources>For Consumers>Fact Sheets on Dietary Supplements>garlic IBIDS Database>Search IBIDS>IBIDS Consumers Database>ginseng (16 hits) Eccles page>Subject links>Consumer Health>Pharmacy>Librarian's Index to the Internet>Alternative Medicine>CAM Therapies for Cancer Patients, etc. Eccles page>Subject links> Consumer Health> Rumors, Hoaxes, and Bogus Information> Ginseng> #2 (FDA)> Aphrodisiac> as you see, it IS bogus http://pioneer.utah.gov Public Pioneer> Internet Resources/Health/UCHIN/Body/MedlinePlus http://UCHIN (from Public Pioneer) Show categories>multilingual (24 Languages)>body>MedlinePlus. Comprehensive>NCCAM site

Online Resources just for starters… MedlinePlus- http://medlineplus.gov/ National Center for Complementary and Alternative Medicine-http://nccam.nih.gov/ Hawaii Health Portal- http://hawaiihealthportal.org Run through each web link and show progression to get to CAM stuff: MedlinePlus.gov (type in box) alternative medicine/What is CAM? Link to NCCAM Subtopics: Cancer Alternative Therapy>Herbal Medicine/Dietary Supplements/Acupuncture Show Clinical Trails links and studies-st john’s wort eg (follow links to other resources) MedlinePlus examples: search in box>ginseng>reiki (get results) but not under “Health topics” Chiropractic can be searched in box or as a health topic Show other parts of MedlinePlus: Spanish>news>Senior Health… http://nccam.nih.gov>health information>treatment information>by treatment or therapy>chiropractic (see articles on scientific research) Ginseng & reiki not listed under health information See clinical trails>ginseng>reiki (listed) http://hawaiihealthportal.org>Consumer Health Information Service (CHIS)>Alternative Medicine>Online Databases>Alternative Medicine Guide>The Natural Pharmacist>Herbs & Supplements>ginseng only listed>search box>chiropractic (51 hits)>search>reiki (14 hits)

In Summary… CAM is a legitimate part of evidence-based medicine and therefore important to provide to patrons if high quality Use MedlinePlus & NCCAM links for quality information Be aware more and more CAM is being focused on by patrons Consumer Health: An Evidence Based Approach to CAM-NN/LM MCR course http://nnlm.gov/mcr/consumer_health/cam/ The bibliography we are handing out includes the websites we have discussed. For the full course see http:nnlm.gov/mcr/consumer.health/cam/ And remember, this class was a condensation of a 2-day class, and we have just boiled it down to 50 minutes. We hope it stimulates your interest but it is just the beginning of a very rich topic.

Bibliography Eccles Health Sciences Library http://medlib.med.utah.edu/ Librarians’ Index to the Internet www.lii.org Utah Public Pioneer - http://pioneer.utah.gov/ Utah Consumer Health Information Network-UCHIN-(look for on Public Pioneer) - http://uchin.med.utah.edu/

Bibliography MedlinePlus- http://medlineplus.gov/ National Center for Complementary and Alternative Medicine -http://nccam.nih.gov/ Hawaii Health Portal -http://hawaiihealthportal.org Evaluation of Health Information: http://www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html http://nccam.nih.gov/health/webresources/

Bibliography for History of CAM (All sites accessed 3/19/04) Traditional Chinese Medicine http://www.tcminternational.com/traditionalchinesemedicine.htm http://www.nmns.edu.tw/New/Introduction/nmns/e/6-1.htm Homeopathy http://bmj.bmjjournals.com/cgi/content/full/319/7217/1115

Bibliography for History of CAM (All sites accessed 3/19/04) Acupuncture http://www.americanacupuncture.com/history.htm Ayurveda http://enotalone.com/article/2289.html Unconventional Medicine http://www.corsello.com/politics/WarAgainstMedicine.pdf