2
Prevalence, Cost, and Patterns of CAM Use

OVERALL USE

The first nationally representative survey of prevalence, costs, and patterns of use of complementary and alternative medicine (CAM) involved a random sample of 1,539 adults who were interviewed by phone in 1990. That survey inquired about the use of 16 CAM therapies and reported that one in three respondents (34 percent) had used at least one complementary therapy during the past year to treat their most serious or bothersome medical condition(s). It also found that those who saw providers for CAM therapies made an average of 19 visits per year, that complementary therapies were used primarily for chronic conditions as opposed to acute or life-threatening conditions, and that CAM therapies were predominantly used in addition to—and not as replacements for—conventional medical therapies. Importantly, it also found that 72 percent of CAM therapy users did not inform their medical doctors that they used CAM (Eisenberg et al., 1993).

Extrapolation of the results of the 1990 survey to the U.S. population suggests that in 1990 Americans made an estimated 425 million visits to providers of complementary care. This number exceeded the number of visits to U.S. primary care physicians (388 million) and was associated with an annual expenditure of approximately $13.7 billion, three-quarters of which ($10.3 billion) were paid out of pocket. This amount was comparable to the $12.8 billion spent out of pocket annually for all hospitalizations in the United States.

A national follow-up survey indicated a dramatic increase in CAM use



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Complementary and Alternative Medicine in the United States 2 Prevalence, Cost, and Patterns of CAM Use OVERALL USE The first nationally representative survey of prevalence, costs, and patterns of use of complementary and alternative medicine (CAM) involved a random sample of 1,539 adults who were interviewed by phone in 1990. That survey inquired about the use of 16 CAM therapies and reported that one in three respondents (34 percent) had used at least one complementary therapy during the past year to treat their most serious or bothersome medical condition(s). It also found that those who saw providers for CAM therapies made an average of 19 visits per year, that complementary therapies were used primarily for chronic conditions as opposed to acute or life-threatening conditions, and that CAM therapies were predominantly used in addition to—and not as replacements for—conventional medical therapies. Importantly, it also found that 72 percent of CAM therapy users did not inform their medical doctors that they used CAM (Eisenberg et al., 1993). Extrapolation of the results of the 1990 survey to the U.S. population suggests that in 1990 Americans made an estimated 425 million visits to providers of complementary care. This number exceeded the number of visits to U.S. primary care physicians (388 million) and was associated with an annual expenditure of approximately $13.7 billion, three-quarters of which ($10.3 billion) were paid out of pocket. This amount was comparable to the $12.8 billion spent out of pocket annually for all hospitalizations in the United States. A national follow-up survey indicated a dramatic increase in CAM use

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Complementary and Alternative Medicine in the United States by the American public between 1990 and 1997 (Eisenberg et al., 1998). (See Table 2-1 for a summary of the surveys of CAM use that have been conducted.) Specifically: The prevalence of CAM use increased by 25 percent from 33.8 percent in 1990 to 42.1 percent in 1997. The prevalence of herbal remedy use increased by 380 percent. The prevalence of high-dose vitamin use increased by 130 percent. The total number of visits to CAM providers increased by 47 percent from 427 million in 1990 to 629 million in 1997. The total visits to CAM providers (629 million) exceeded the total number of visits to all primary-care physicians (386 million) in 1997. It was estimated that, in 1997, adults made 33 million office visits to professionals for advice regarding the use of herbs and high-dose vitamins. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies or high-dose vitamins or both. These individuals are therefore at risk for potential adverse drug-herb or drug-supplement interactions. If insurance coverage for CAM therapies increases in the future, current use of CAM services is likely an under-represention of future utilization patterns. Despite the dramatic increases in the rates of use and the expenditures associated with CAM services, the extent to which patients disclosed their use of CAM therapies to their physicians remains low. In both 1990 and 1997, less than 40 percent of CAM therapy users disclosed to their physicians that they had used such therapies. Estimated expenditures for CAM professional services increased by 45 percent, exclusive of inflation. In 1997 such expenditures were estimated to be $21.2 billion. Out-of-pocket expenditures for herbal products and high-dose vitamins in 1997 were estimated to be $8.0 billion. Out-of-pocket expenditures for CAM professional services in 1997 were estimated to be $12.2 billion. This exceeded the out-of-pocket expenditures for all U.S. hospitalizations. Total out-of-pocket expenditures relating to CAM therapies were conservatively estimated to be $27.0 billion. This is comparable to the projected out-of-pocket expenditures for all U.S. physician services. The study also found that among the respondents who in the past year had used CAM and seen their medical doctor, 63 to 72 percent did not disclose to their doctor the fact that they had received at least one type of CAM therapy. Among 507 respondents who reported their reasons for

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Complementary and Alternative Medicine in the United States TABLE 2-1 Use of Complementary/Alternative Medicine by U.S. Adults Author (year) Nature of Sample/Survey Response Rate (%) Description of Sample Barnes et al. (2004) Representative sample, n = 31,044, computer assisted personal interviews 74.3 Adults aged >18 years. Data were age adjusted to 2000 U.S. standard population Ni et al. (2002) Representative sample, n = 30,801, computer assisted personal interviews 70 Data from 1999 National Health Interview Survey. Adults aged >18 years. Data were age adjusted to 1999 U.S. population Eisenberg et al. (1998) Random, n = 2,055, telephone interview 60 Random sample of U.S. population 52% female 77% white

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Complementary and Alternative Medicine in the United States Questions Asked Prevalence Figures by Therapy (%) Questions were part of the 2002 National Health Interview Survey. Questions asked about use (ever and during past 12 months) of 27 types of CAM therapies (10 provider-based, and 17 non-provider based). If a CAM therapy was used in the last 12 months, respondents were also asked about: condition being treated; reason for choosing therapy, insurance coverage for costs; satisfaction with treatment; and whether conventional practitioner knew about CAM use. Overall, in 2002, about 62% of U.S. adults used some form of CAM in the past 12 months. 10 CAM therapies most commonly used in past 12 months: 43.0% prayer for one’s own health 24.4% prayer by other’s for one’s own health 18.9% natural products 11.6% deep breathing exercises 9.6% participation in prayer group for one’s own health 7.6% meditation 7.5% chiropractic care 5.1% yoga 5.0% massage 3.5% diet-based therapies Medical Conditions: CAM most often used for back pain or problems, head or chest colds, neck pain or problems, joint pain or stiffness, and anxiety or depression. Questions were part of the 1999 National Health Interview Survey. Participants were asked if, during the past 12 months, they had used any CAM therapies (from a list of 11). 28.9% of U.S. adults used at least one CAM therapy during the past year. Most commonly used therapies: 13.7% spiritual healing or prayer 9.6% herbal medicine 7.6% chiropractic therapies 6.9% lifestyle diet 6.4% massage therapy 5.0% relaxation 3.1% homeopathy 1.7% imagery 1.4% acupuncture 1.1% energy 0.5% hypnosis 0.5% biofeedback 0.3% other (e.g., qi gong, yoga, chelation, and bee stings) Have you ever used any of the following forms of CAM (16 named) to treat your principle medical conditions? If so, have you done so within the last 12 months? Used in the last 12 months: 42.0% at least one CAM 13.0% relaxation technique 12.0% herbal medicine 11.0% massage 11.0% chiropractic

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Complementary and Alternative Medicine in the United States Author (year) Nature of Sample/Survey Response Rate (%) Description of Sample Astin (1998) Random sample of adults in the U.S., n = 1,035, representative of U.S. population 69 National Family Opinion Survey (USA) Age ≤ 18 51% female 80% white 30% high school or less 12% ≤12,500 annual income Paramore (1997) Representative, n = 3,450 75 Sample from the National Access to Care Survey Eisenberg et al. (1993) Representative, random, n = 1,539, telephone interview 67 Random sample from USA 48% female 34% aged > 50 years 32% white Sample recruited through random digit dialing nondisclosure, common reasons were “It wasn’t important for the doctor to know” (61 percent), “The doctor never asked” (60 percent), “It was none of the doctor’s business” (31 percent), and “The doctor would not understand” (20 percent). Fewer respondents (14 percent) thought that their doctor would disapprove of or discourage CAM use, and just 2 percent thought that the doctor might not continue as their provider if the doctor knew that the patient had received some sort of CAM therapy. The respondents judged CAM therapies to be more helpful than conventional care for the treatment of headache and neck and back conditions, but they considered conventional care to be more helpful than CAM therapy for treatment of hypertension. Adults who use both CAM and conventional medicine appear to value both and tend to be less concerned about their medical doctors’ disapproval than they are about their doctors’ inability to understand or incorporate CAM therapy use within the context of their medical management (Eisenberg et al., 1998). Paramore (1997) analyzed data from a national database composed of survey data for 3,450 individuals. The survey indicated that in 1994 approximately 10 percent of the adult population (25 million individuals) had seen a professional for at least one of four CAM therapies: chiropractic,

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Complementary and Alternative Medicine in the United States Questions Asked Prevalence Figures by Therapy (%) Have you used any of the following forms of CAM (17 named) within the past year? 40% has used CAM in the past year 16.0% chiropractic 8.0% lifestyle diet 7.0% exercise 7.0% relaxation In the last year, did you see a professional for one of four therapies? 6.8% chiropractic 3.1% therapeutic massage 1.3% relaxation techniques 0.4% acupuncture Have you ever used any of the following therapies (16 named) to treat your principle medical conditions? If so, have you done so within the last 12 months? Used in the last 12 months: 34.0% at least one CAM 13.0% relaxation techniques 10.0% chiropractic 7.0% massage relaxation techniques, therapeutic massage, or acupuncture. The majority of those who sought professional care from CAM providers also saw a medical doctor during the reference year. The study also observed that users of CAM therapies made almost twice as many visits to conventional medical providers as non-CAM users. Astin (1998) conducted a mail survey of 1,035 randomly selected individuals. Forty percent of those responding (response rate 69 percent) reported CAM use during the previous year. Another survey reported by Druss and Rosenheck (1999) investigated the association between the use of CAM therapies and the use of conventional care in a different national survey sample taken from the 1996 Medical Expenditure Panel survey. They reported that in 1996 an estimated 6.5 percent of the U.S. population visited both CAM providers and conventional medical practitioners. Fewer than 2 percent used only CAM services, 60 percent used only conventional care, and 32 percent used neither. These numbers were considerably lower than the range reported by Eisenberg et al. (1998). The investigators concluded that, from the health services perspective, practitioner-based CAM therapies appear to serve more as a complement than as an alternative to conventional medical care.

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Complementary and Alternative Medicine in the United States In 1999, the National Health Interview Survey (NHIS) included questions about the use of alternative health care practices. Ni et al. (2002) analyzed the data from the 1999 NHIS which included 30,801 respondents and an oversampling of non-English speakers and those without telephones. A total of 12 types of CAM were asked about in the survey. Ni et al. documented a CAM use prevalence rate of 28.9 percent during the prior 12 months. The investigators concluded that on the basis of these data in 1999, CAM use was somewhat lower than that in previous surveys. Most CAM therapies were used in conjunction with conventional medical services, a finding consistent with prior observations. Lastly, the investigators pointed out that the discrepancies in overall prevalence of CAM use may largely result from the lack of agreement in the definitions of “complementary and alternative medicine.” The lack of consensus regarding a definition as to what is or what is not to be included in the category of complementary and alternative medicine has unquestionably complicated efforts to document, in a consistent fashion, the prevalence, patterns, and costs of CAM use by the American public. Barnes and colleagues (2004) performed the most recent national analysis of CAM use using data from the 2002 NHIS. The survey included 31,044 respondents, drawn from a nationally representative sample. The 2002 survey expanded on the CAM-related questions asked in 1999, inquiring about 27 types of CAM therapies, the condition being treated, the reasons for choosing a CAM therapy, whether insurance covered the CAM therapy, the level of satisfaction with the treatment, and whether the individual’s conventional medical practitioner knew about the patient’s CAM use. As with previous surveys, clearly defining CAM had a large impact on the prevalence results. When “prayer for one’s own health” was included in the definition, Barnes et al. found that 75 percent of adults had ever used CAM and that 62 percent of adults had used some form of CAM therapy within the past 12 months. Excluding prayer from the definition decreased the rate of CAM use to 36 percent. The 2002 NHIS did not collect data about how much money is spent on CAM therapies, but it did report that 13 percent of CAM users chose CAM because conventional medicine was too expensive. The patterns of CAM use described above are all based on nationally representative random samples of the adult U.S. population. As such, their results are more generalizable than data obtained from smaller clinic- and community-based surveys, which typically focus on specific health problems and specific age cohorts (Bair et al., 2002; Davis and Darden, 2003; Lee et al., 2000a), ethnic groups or geographic areas (Cushman et al., 1999; Factor-Litvak et al., 2001; Greendale et al., 2003; Maskarinec et al., 2000; Najm et al., 2003; Vallerand et al., 2003), and special at-risk populations,

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Complementary and Alternative Medicine in the United States such as homeless youth (Breuner et al., 1998). These smaller surveys, along with qualitative studies provide insights into the health-care seeking behaviors of local populations. USE BY POPULATION SUBGROUPS Women The use of CAM therapies is more common among women (48.9 percent) than men (37.8 percent) (Eisenberg et al., 1998). Wootton and Sparber (2001a,b,c) also noted this trend in their review of surveys on CAM use, as did Barnes et al. (2004) in their survey. The fact that women use CAM therapies more commonly than men is noteworthy. Women’s greater use of health care services in general has been critically examined in the health social science literature in relation to such variables as social class, longevity, patterns of morbidity, symptom reporting, psychosocial distress, and gender-based differences in health care provision (Bertakis et al., 2000; Gijsbers van Wijk et al., 1992; Macintyre et al., 1996; Mustard et al., 1998). Two observations are relevant. First, women tend to be more health conscious than men leading them to invest more time and resources in promotive and preventive health (Hibbard and Pope, 1983; Verbrugge and Wingard, 1987). Second, women tend to serve as domestic health care managers influencing the health care behavior of family members, particularly when they are ill and at home (Barnett and Baruch, 1987; Carpenter, 1980; Clark, 1995; Michelson, 1990; Umberson, 1992; Verbrugge, 1989). This suggests that women’s use of CAM modalities may well serve as an indicator of probable family use of CAM in the future. Education and Income Eisenberg and colleagues (1998) found that CAM use was higher among those who had some college education (50.6 percent) than among those with no college education (36.4 percent) and was more common among people with annual incomes above $50,000 (48.1 percent) than among those with lower incomes (42.6 percent). Foster et al. (2000), who examined a different aspect of the database of Eisenberg et al. (1998), explored the relationship between income and CAM use. They observed that complementary therapy use varied by income quartile (43 percent CAM use among those with annual incomes less than $20,000; 37 percent among those earning $20,000 to $30,000 per year; 44 percent among those earning $30,000 to $50,000 per year; and 48 percent among those with annual incomes above $50,000). In addition, the average annual out-of-pocket expenditures increased with income quartile confirming that those with

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Complementary and Alternative Medicine in the United States higher incomes used more CAM therapies overall. Interestingly, although the data indicating that CAM use appears to be highest among those with more financial resources, the data also show that 43 percent of those in the lowest income group (those with incomes less than $20,000 per year) used CAM therapies routinely, suggesting that CAM use is prevalent in all sociodemographic segments of society (Eisenberg et al., 1998). In the Astin (1998) survey, level of education was positively correlated with CAM use. Astin reported that 31 percent of survey participants with a high school education or less used CAM, and the rate of use increased to 50 percent for participants with a graduate degree. Household income was not a predictive factor of use, and as in the analysis of Foster et al. (2000), Astin found CAM use to be prevalent at multiple socio-demographic levels, ranging from 33 percent among those with incomes <$12,500 to 44 percent among those with incomes >$40,000. Wootton and Sparber (2001) found that CAM users are primarily middle-aged, better educated, and in higher income brackets. However, they report that little is known about the rate of use among the less well to do since only a few small-scale studies of CAM use by low-income groups exist. Their analysis of these small-scale studies found that 29 percent (n = 199) of patients on Medicaid in a family health center used CAM; 70 percent (n = 157) of homeless young people in the Street Clinic youth program in Seattle, Washington, reported using CAM; and 56 percent (n = 187) of patients attending a family practice clinic reported using herbs/supplements. For many types of CAM therapies, Barnes et al. (2004) found that the rate of use increased as the level of education increased. This pattern was seen for biologically based therapies, alternative medical systems, energy therapies, and manipulative and body-based therapies. The analysis of CAM use by income revealed an interaction between the type of therapy and income. Individuals who were poor1 exhibited a slightly higher prevalence of megavitamin therapy and prayer use than individuals who were not poor (65.5 and 62.6 percent, respectively). However, individuals who were not poor reported higher rates of use of biologically based therapies (excluding megavitamin therapy), mind-body therapies (excluding prayer), alternative medical systems, energy therapies, and manipulative and body-based therapies than poor individuals. 1   “Poverty” was defined by the Census Bureau’s 2001 thresholds. “Poor” was defined as an income below the poverty threshold, and “not poor” was defined as an income >200 percent of the poverty threshold.

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Complementary and Alternative Medicine in the United States Ethnicity and Culture Eisenberg and colleagues (1998) found CAM use to be less common among African Americans (33.1 percent) than among members of other racial groups (44.5 percent). In Wootton and Sparber’s 2001a review, Dominican patients in an emergency room reported 50 percent use of CAM (n = 50); 94.6 percent (n = 75) of Chinese immigrants reported self-treatment and the use of home remedies; 62 percent (n = 300) of Navajos visiting an Indian Health Service hospital reported that they had used native healers; and 44 percent (n = 213) of Mexican Americans in a convenience sample reported that they had used herbal remedies, and 13 percent reported that they had used curanderismo. Mackenzie and colleagues (2003) further examined the prevalence of CAM use among many different ethnic groups in the United States. They analyzed a subset of data from the 1995 National Comparative Survey of Minority Health Care of The Commonwealth Fund, a national probability sample of 3,789 people with an oversampling of ethnic minorities. The survey was conducted by telephone in six languages. The use of five categories of CAM within the last year were queried (herbal medicine, acupuncture, chiropractic, traditional healer, and home remedy). Overall, 43.1 percent of the respondents reported using one or more of those five CAM modalities. The use of CAM was equally prevalent among white, African-American/black, Latino, Asian, and Native American populations; but the characteristics of the users varied considerably by specific CAM modality. The predictors of CAM use were female gender, being uninsured, and having a high school education or above. These factors were consistent with earlier surveys involving random samples of all U.S. adults. Ni and colleagues (2002) found that overall CAM use was higher for white non-Hispanic individuals (30.8 percent) than for Hispanic (19.9 percent) and black non-Hispanic (24.1 percent) individuals. Like the findings of Mackenzie et al. (2003), the 2002 NHIS (Barnes et al., 2004) found various patterns of use by race, depending on the type of CAM therapy. Use of mind-body therapies including prayer for health reasons was more prevalent among black adults (68.3 percent) than among white (50.1 percent) or Asian (48.1 percent) adults. However, Asian adults (43.1 percent) were more likely to use CAM (excluding megavitamin therapy and prayer) than white (35.9 percent) or black (26.2 percent) adults. Finally, white adults (12 percent) were more likely to use manipulative and body-based therapies than Asian (7.2 percent) or black (4.4 percent) adults. It may be, however, that surveys of minority cultures underestimate health practices such as the use of home remedies since in many cultures, the consumption of foods (including commonly used herbs and spices) for medicinal purposes is so engrained in everyday folk dietetic practices that it

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Complementary and Alternative Medicine in the United States is not recognized as being out of the ordinary or worth reporting. The same may be true for religious-spiritual practices, which serve multiple purposes and which may be reported only under extraordinary circumstances and not as routine ways of coping with adversity or ensuring well-being. There is often a fine line between what members of a minority culture deem normative practice and what outsiders classify as CAM practice. In large surveys with representative samples, there is a need for better, more culturally sensitive questions that will provide more accurate data about CAM use among minority populations. Age In earlier surveys, people aged 35 to 49 years reported higher rates of CAM use (50.1 percent) than people either older (39.1 percent) or younger (41.8 percent) (Eisenberg et al., 1998). Recently, the 2002 NHIS results indicate that CAM use increases with age. Barnes et al. (2004) found that 53.5 percent of the individuals in the youngest age bracket (18 to 29 years) reported that they had used some type of CAM2 and the greatest prevalence of CAM use (70.3 percent) was found among those in the oldest age bracket (85 years and older). Wootton and Sparber’s (2001a) review found that the rate of CAM use among elderly individuals ranged from 33 percent of a convenience sample of elderly patients with cancer (n = 699) to 84 percent of a convenience sample of elderly rural women. Foster et al. (2000), using the data of Eisenberg et al. (1998), measured the prevalence, cost, and patterns of CAM use by people aged 65 or older. They observed that during the previous 12 months 30 percent had used at least one type of CAM therapy for the treatment of their principal medical conditions. The complementary modalities most commonly used by individuals aged 65 and older used were chiropractic, herbal remedies and dietary supplements, relaxation and meditation techniques, and high-dose vitamins. As was the case for the general population, the majority of older adults who used CAM services made no mention of this to their physician. Fewer studies have examined the use of CAM by children. Davis and Darden (2003) analyzed a 1996 nationally representative survey of American children and reported a prevalence rate of 1.8 percent. Among CAM users, 76.8 percent were white and 54 percent were female. CAM use increased with age, with older children (ages 10 to 17 years) accounting for 62.6 percent of the use, but the youngest children (ages 0 to 4 years) representing only 21 percent. The investigators noted that the overall estimate of CAM use was lower than that reported in previous surveys and 2   CAM use included megavitamin therapy and prayer.

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Complementary and Alternative Medicine in the United States CHARACTERISTICS OF CAM THERAPIES PROVIDED BY LICENSED ACUPUNCTURISTS, CHIROPRACTORS, MASSAGE THERAPISTS, AND NATUROPATHS Although much of the information regarding the prevalence and the patterns of CAM use comes from surveys of patients, studies of CAM practitioners aimed at documenting the types of patients whom they see and the types of therapeutic options that they offer have also been conducted. Cherkin et al. (2002a,b) surveyed random samples of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians and collected data on the patients who visited those providers. Specifically, they collected data on 20 consecutive visits to a random sample of licensed CAM therapists in four states (Arizona, Connecticut, Massachusetts, and Washington) and compared the data with data on conventional physician visits from the National Ambulatory Medical Care Survey. The data reported came from at least 99 practitioners in each professional group and were collected for more than 1,800 ambulatory visits. More than 80 percent of the visits to CAM providers were by young and middle-aged adults, and roughly two-thirds were by women. Children made 10 percent of the visits to naturopathic physicians but only 1 to 4 percent of all visits to all other CAM providers. At least two-thirds of the visits resulted from self-referrals, and only 4 to 12 percent of the visits were a result of referrals by conventional physicians. Chiropractors and massage therapists primarily saw patients with musculoskeletal problems (e.g., patients with back, neck, and shoulder symptoms), whereas acupuncturists and naturopathic physicians saw a broader range of conditions (including fatigue, mental health issues, and headaches). Visits to acupuncturists and massage therapists lasted about 60 minutes, whereas visits to naturopathic physicians lasted 40 minutes, those to chiropractors lasted less than 20 minutes, and a routine visit with a conventional physician lasted less than 10 minutes. Most visits to chiropractors and naturopathic physicians but less than one-third of visits to acupuncturists and massage therapists were covered by insurance. The investigators commented on the observation that CAM providers typically did not discuss with the conventional doctors the care that they were providing to patients who were concurrently seeking care from conventional doctors. This finding, they argue, in conjunction with the fact that patients rarely discussed their CAM care with their conventional physicians raises concerns about the coordination and safety of concurrent care. A lack of coordination and safety issues are of particular concern when care is provided by acupuncturists and naturopathic physicians, who might prescribe herbs that interact with medication prescribed by conventional physicians and vice versa. The investigators noted that although the overlap in the types of prob-

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Complementary and Alternative Medicine in the United States lems addressed by the four CAM professions is considerable, each profession has unique aspects. Chiropractors and massage therapists see the narrowest range of medical problems. However, chiropractors and massage therapists were the most likely to provide care not related to illness (e.g., care for wellness and prevention). Care for conditions other than illness in massage patients, which represented almost one in five visits, was focused on relaxation and stress reduction. Massage therapists also tend to see a substantial number of patients for self-reported anxiety or depression, some of whom might also want help relaxing and coping with stress. Another distinctive aspect of chiropractic care is the relatively large role that it plays in caring for acute conditions: about 40 percent of chiropractic visits are for acute conditions, whereas roughly 20 percent of visits to other CAM professionals are for acute conditions. As noted above, acupuncturists and naturopathic physicians see a broader range of conditions than chiropractors and massage therapists do and often provide care for such problems as anxiety, depression, fatigue, allergies, skin rashes, and menopausal symptoms. The investigators commented that the most notable differences between the practices of conventional physicians (i.e., medical doctors and doctors of osteopathy) compared with those of CAM providers was the relatively large fraction of visits to the former for routine physical examinations, screening, and diagnostic tests and for symptoms associated with respiratory tract infections. CONCLUSIONS AND RECOMMENDATIONS As can be seen from the information presented in this chapter, an estimated 30 to 62 percent of adults in the United States use CAM. A lack of consensus on the definition of CAM has led to inconsistencies among the reports of various surveys on CAM prevalence and patterns of use. Total out-of-pocket expenditures for CAM therapies were conservatively estimated to be $27.0 billion in 1997. This is comparable to the projected out-of-pocket expenditures for all U.S. physician services (Eisenberg et al., 1998). The majority of CAM use is not reimbursed by insurance at present; however, data indicate that prevalence rates are likely to increase as third-party reimbursements for CAM benefits become increasingly available (Eisenberg et al., 1998; Wolsko et al., 2002). High-frequency users of CAM tend to be high-frequency users of health care in general and account for approximately 80 percent of the total expenditures on CAM. Many appear to use CAM for wellness and not just the treatment of disease (Wolsko et al., 2002). Women tend to use CAM more than men, and educated individuals tend to use CAM more than poorly educated individuals (Eisenberg et al., 1998; Wootton and Sparber, 2001a). However, CAM use is common

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Complementary and Alternative Medicine in the United States among people in all ethnic groups (Barnes et al., 2004; Eisenberg et al., 1998; Mackenzie et al., 2003; Ni et al., 2002). Although Eisenberg et al. (1993) and Wolsko et al. (2002) did find that a significant percentage of CAM use is unsupervised and engaged in as self-care, existing surveys reveal little about what percentage of CAM use is self-initiated (“I go to a provider and ask for X”), provider initiated (“I go to a provider, and she recommends or administers X”), provider administered (“She does X to me [massage, acupuncture, chiropractic]), or self-administered (“I read how to do it or someone shows me, and then I do it myself in a fashion I find comfortable; I self-regulate herbs, etc.).” Furthermore, few data are available on how the American public makes decisions about accessing CAM therapies. Finally, although there is an extensive literature on adherence to conventional treatment, there are virtually no data on rates of adherence to CAM treatment or self-treatment with CAM. This information is crucial to assessments of the real-world effectiveness and safety of CAM use. A majority of patients who use CAM do not disclose such use to their physicians. Nondisclosure raises important safety issues, for example, the potential interactions of medications with herbs used as part of a CAM therapy. In addition, a majority of adults who use CAM therapies use more than one CAM modality and do so in combination with conventional medical care (Wolsko et al., 2002). Most adults who use both conventional and CAM therapies tend to value both for different purposes (Druss and Rosenheck, 1999; Eisenberg et al., 2001). Additionally, given the high rates of use of both CAM and conventional medicine by those with chronic conditions, there is a need for a better understanding of what motivates patients with such conditions to seek both CAM and conventional medical services and the cost implications of combined care. The motivations for using CAM are numerous and are poorly captured by large-scale surveys; however, a major contributor appears to be the pursuit of wellness (Astin, 1998; Kessler et al., 2001; Wolsko et al., 2002). The extent to which CAM use is a trigger for positive behavioral change is unknown, however, and constitutes an important research issue because of the benefit of positive behavioral change to the public’s health and its use as a means to address the escalating costs of health care. Longitudinal cohort studies can clarify people’s trajectories of CAM use and those factors that influence upward and downward rates of use. Research designs that enable examination of patterns of CAM use need to be developed, as the patterns of CAM use are affected by external variables and influence other patterns of behavior important for health (e.g., diet, exercise, and substance use). Studies similar in structure to the Framingham Heart Study or the Nurses’ Health Study (both of which are ongoing and which could be expanded to include questions about CAM) may offer the best opportunity to explore

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Complementary and Alternative Medicine in the United States the patterns of CAM use over time and the role of CAM (or lack thereof) in promoting health, reducing risk, and preventing disease. There is also little research on how the public obtains information about CAM modalities; what types of information are deemed credible, marginal, and spurious; how the public understands the information in terms of risks and benefits and how such perceptions inform decision making; and what the public expects providers to tell them. The few small studies that do exist illustrate that considerable misinformation is dispersed by vendors and on the Internet (Ashar et al., 2003; Bonakdar, 2002; Glisson et al., 2003; Matthews et al., 2003; Mills et al., 2003; Morris and Avorn, 2003). It is important to understand more about how the public is accessing information and making decisions about CAM use to move toward informed decision making about such therapies. Furthermore, closer monitoring of websites, enforcement of DSHEA and Federal Trade Commission regulations, and the creation of a user-friendly authoritative website on CAM modalities are needed. As a means to address the lack of information discussed above, the committee recommends that the National Institutes of Health and other public or private agencies sponsor quantitative and qualitative research to examine The social and cultural dimensions of illness experiences, health care-seeking processes and preferences, and practitioner-patient interaction; How often users of CAM, including patients and providers, adhere to treatment instructions and guidelines; The effects of CAM on wellness and disease prevention; How the American public accesses and evaluates information about CAM modalities; and Adverse events associated with CAM therapies and interactions between CAM and conventional treatments. Periodic surveys, especially in-depth instruments, would allow assessment of aspects of CAM prevalence, cost, and patterns of use that would not otherwise be captured by sentinel surveillance sites or ongoing, federally funded surveys. As discussed throughout this chapter we have little information about many aspects of CAM use. Surveys could, for example, provide much needed information about out-of-pocket costs and insured coverage for individual therapies; about the ingestion of individual prescription drugs, over-the-counter preparations, herbs, and supplements; the frequency of disclosure to one’s doctor, nurse, pharmacist, or CAM provider about use of CAM therapies and the reasons for nondisclosure; and compliance issues including whether or to what extent use of CAM inter-

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Complementary and Alternative Medicine in the United States feres with compliance with conventional treatments. Surveys could explore in depth the motivations for using CAM and investigate perceptions about various CAM therapies (and therapists) as compared with conventional therapies or therapists, stratified by disease, complaint, or CAM modality. Surveys are needed to provide information about how people obtain information about CAM; to investigate the impact of one person’s CAM involvement on that person’s immediate family or larger social network; and the impact of direct advertising to the public or the influence of CAM therapists and retailers of CAM products. Further, the committee recommends that the National Library of Medicine and other federal agencies develop criteria to assess the quality and reliability of information about CAM. When implementing the above recommendation regarding information about CAM, available criteria for assessment of health information in general should be examined and the applicability (or lack thereof) of existing criteria to CAM should be evaluated. REFERENCES Adler SR. 1999. Complementary and alternative medicine use among women with breast cancer. Med Anthropol Q 13(2):214–222. Allaire AD, Moos MK, Wells SR. 2000. Complementary and alternative medicine in pregnancy: A survey of North Carolina certified nurse-midwives. Obstet Gynecol 95(1): 19–23. Arora NK. 2003. Interacting with cancer patients: The significance of physicians’ communication behavior. Soc Sci Med 57(5):791–806. Ashar BH, Miller RG, Getz KJ, Pichard CP. 2003. A critical evaluation of Internet marketing of products that contain ephedra. Mayo Clin Proc 78(8):944–946. Astin JA. 1998. Why patients use alternative medicine: Results of a national study. JAMA 279(19):1548–1553. Astin JA, Pelletier KR, Marie A, Haskell WL. 2000. Complementary and alternative medicine use among elderly persons: One-year analysis of a Blue Shield Medicare supplement. J Gerontol A Biol Sci Med Sci 55(1):M4–M9. Bair YA, Gold EB, Greendale GA, Sternfeld B, Adler SR, Azari R, Harkey M. 2002. Ethnic differences in use of complementary and alternative medicine at midlife: Longitudinal results from SWAN participants. Am J Public Health 92(11):1832–1840. Barnes PM, Powell-Griner E, McFann K, Nahin RL. 2004. Complementary and alternative medicine use among adults: United States, 2002. Vital Health and Statistics 343:1–19 (advance data). Baruch GK, Biener L, Barnett RC. 1987. Women and gender in research on work and family stress. Am Psychol 42(2):130–136. Beal MW. 1998. Women’s use of complementary and alternative therapies in reproductive health care. J Nurse Midwifery 43(3):224–234. Bernstein BJ, Grasso T. 2001. Prevalence of complementary and alternative medicine use in cancer patients. Oncology (Huntington) 15(10):1267–1272. Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA. 2000. Gender differences in the utilization of health care services. J Fam Pract 49(2):147–152.

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