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Jeff Sutherland

Twice the Energy with Half the Stress

IOM 2005 Complementary and Alternative Medicine

National Institute of Medicine (2005) Complementary and Alternative Medicine. National Academies Press

Americans’ use of complementary and alternative medicine (CAM) —approaches such as chiropractic or acupuncture—is widespread. More than a third of American adults report using some form of CAM, with total visits to CAM providers each year now exceeding those to primary-care physicians. An estimated 15 million adults take herbal remedies or high-dose vitamins along with prescription drugs. It all adds up to annual out-of-pocket costs for CAM that are estimated to exceed $27 billion.

Friends confer with friends about CAM remedies for specific problems, CAM-related stories appear frequently in the print and broadcast media, and the Internet is replete with CAM information. Many hospitals, managed care plans, and conventional practitioners are incorporating CAM therapies into their practices, and schools of medicine, nursing, and pharmacy are beginning to teach about CAM.

CAM’s influence is substantial yet much remains unknown about these therapies, particularly with regard to scientific studies that might convincingly demonstrate the value of individual therapies. Against this background the National Center for Complementary and Alternative Medicine (NCCAM), 15 other centers and institutes of the National Institutes of Health (NIH), and the Agency for Healthcare Research and Quality commissioned the Institute of Medicine (IOM) to convene a committee that would:

  • Describe the use of CAM therapies by the American public and provide a comprehensive overview, to the extent that data are available, of the therapies in widespread use, the populations that use them, and what is known about how they are provided.
  • Identify major scientific, policy, and practice issues related to CAM research and to the translation of validated therapies into conventional medical practice.
  • Develop conceptual models or frameworks to guide public- and private-sector decisionmaking as research and practice communities increasingly conduct research on CAM, translate the research findings into practice, and address the barriers that may impede such translation…

This report’s core message is therefore as follows: The committee recommends that the same principles and standards of evidence of treatment effectiveness apply to all treatments, whether currently labeled as conventional medicine or CAM… The committee acknowledges that the characteristics of some CAM therapies—such as variable practitioner approaches, customized treatments, “bundles” (combinations) of treatments, and hard-to-measure outcomes—are difficult to incorporate into treatment-effectiveness studies. These characteristics are not unique to CAM, but they are more frequently found in CAM than in conventional therapies…

But while randomized controlled trials (RCTs ) remain the “gold standard” of evidence for treatment efficacy, other study designs can be used to provide information about effectiveness when RCTs cannot be done or when their results may not be generalizable to the real world of CAM practice. These innovative designs include:

  • Preference RCTs: trials that include randomized and non-randomized arms, which then permit comparisons between patients who chose a particular treatment and those who were randomly assigned to it
  • Observational and cohort studies, which involve the identification of patients who are eligible for study and who may receive a specified treatment, but are not randomly assigned to the specified treatment as part of the study
  • Case-control studies, which involve identifying patients who have good or bad outcomes, then “working back” to find aspects of treatment associated with those different outcomes
  • Studies of bundles of therapies: analyses of the effectiveness, as a whole, of particular packages of treatments
  • Studies that specifically incorporate, measure, or account for placebo or expectation effects: patients’ hopes, emotional states, energies, and other self-healing processes are not considered extraneous but are included as part of the therapy’s main “mechanisms of action”
  • Attribute-treatment interaction analyses: a way of accounting for differences in effectiveness outcomes among patients within a study and among different studies of varying design