Western biomedicine is the predominant health care system in the United States and other Western countries. However, during the past 30 years, a growing interest in complementary (together with traditional treatment) and alternative (in place of traditional treatment) medicine has rapidly evolved. Complementary and alternative medicine (CAM) is a diverse group of systems, practices, and products that are not an official part of today’s U.S. traditional biomedical health care system. However, there is growing scientific evidence that some CAM therapies are as effective as traditional or conventional therapies. Integrative medicine combines therapies from traditional Western medicine and CAM. A growing number of health care systems have an integrated medicine or CAM department.

Most people who seek complementary and alternative therapies pay for them out-of-pocket because most third-party payers reimburse for only selected therapies such as chiropractic treatment and acupuncture. More women than men and people with high formal educational levels are most likely to use CAM (National Center for Complementary and Alternative Medicine [NCCAM], 2008).

Unlike traditional medicine, CAM therapies are part of the holistic care movement—the connection and integration of the mind, body, and spirit. Four common alternative holistic systems practiced in the United States are homeopathic, naturopathic, Ayurvedic, and Traditional Chinese Medicine. Homeopathic and naturopathic medicine started in Germany in the 1800s and have been used in the United States for less than 100 years. Ayurvedic medicine originated in India over 3000 years ago and is gaining popularity in the United States. Traditional Chinese Medicine is the oldest medical system in the world and is commonly practiced in the United States today. Acupressure and acupuncture therapies are used most often; these therapies are described on p. 12 in this chapter.

Homeopaths plan individualized care by prescribing small doses of specially prepared plant and animal extracts and minerals to promote healing. Naturopaths are more holistic in that they use a combination of physical therapies, herbal preparations, homeopathic remedies, acupuncture, and lifestyle changes to improve health. Both homeopaths and naturopaths complete specialized training and certification but are not recognized in all U.S. states. Practitioners of Ayurvedic medicine (also called Ayurveda) employ a variety of CAM therapies to eliminate impurities from the body, reduce symptoms, increase resistance to disease, and promote balance and harmony. Examples of therapies used for these purposes include meditation, massage, herbs, and exercise (NCCAM, 2011c).

Nurses and other health care providers believe in a holistic, caring approach to practice. Many CAM therapies do not require special or advanced training to use them with patients. Others, such as acupuncture, require specialized education and, in some states, licensure or certification. This chapter briefly introduces some of the common CAM therapies used by patients and nurses in a variety of settings. More detailed discussions of specific CAM usage for selected health problems and associated nursing implications are found throughout this text in sections labeled with the heading “Complementary and Alternative Therapies.” Medical-surgical nurses play a key role in assessing the need for CAM and teaching patients and their families about how to safely use CAM therapies.

National Center for Complementary and Alternative Medicine

As a result of growing interest in CAM, the National Institutes of Health established the National Center for Complementary and Alternative Medicine (NCCAM). The purposes of this center are to:

• Fund studies examining the effectiveness of various complementary therapies

• Advance the knowledge about complementary therapies of health professionals

• Serve as a clearinghouse for information about these therapies

NCCAM classifies complementary and alternative medicine into four major categories, as summarized in Table 2-1. These categories include:

• Natural products

• Mind-body therapies

• Manipulative and body-based therapies

• Other CAM modalities, such as energy and cognitive-behavioral therapies

TABLE 2-1

NCCAM CATEGORIES OF CAM WITH EXAMPLES

DOMAIN	EXAMPLES
Natural products	Neutraceuticals (dietary supplements), such as calcium and magnesium; probiotics, including foods (e.g., yogurt) and supplements (e.g., Lactobacillus)
Mind-body therapies	Imagery, meditation, music, humor, biofeedback, yoga, prayer, pet therapy
Manipulative and body-based therapies	Chiropractic treatment, massage, tai chi
Other CAM therapies	Healing Touch, Therapeutic Touch, Reiki

CAM, Complementary and alternative medicine; NCCAM, National Center for Complementary and Alternative Medicine.

Cam Categories

Natural Products

Most natural products are either neutraceuticals (dietary and herbal supplements) or probiotics. As a group, these products are thought to provide health and medical benefits and are used widely, especially by older adults (Zarowitz, 2010). In the United States, neutraceuticals and probiotics are regulated as food and nutritional supplements by the Food and Drug Administration (FDA). However, these regulations are less strict than those for drug therapy, which has raised increasing concern about their safety. Dietary and herbal supplements do not receive the same stringent oversight in their preparation and use as drugs. Therefore they cause a range of patient responses depending on their nature and how they were prepared. Herbal preparations that are sold as standardized extracts are more likely to contain larger amounts of the herb or nutritional element and less likely to contain inactive ingredients or fillers. Teach patients that because an herb is labeled as “natural,” it does not mean that the herb is safe. Because it may be safe does not mean that it is effective.

Some dietary and herbal supplements have pharmacoactive effects that can be serious or deadly, as in cases of overuse, inappropriate use, supplement toxicities, and supplement-drug and supplement-supplement interactions.

Considerations for Older Adults

Older adults in the community often overuse dietary and herbal supplements to help prevent potentially life-threatening health problems and promote quality of life. For example, older women may take too much calcium because they want to prevent osteoporosis. As a result, excess calcium can deposit in kidneys as renal calculi (stones). Teach women the importance of collaborating with their health care provider to monitor serum calcium levels and kidney function before and during calcium supplementation.

Older adults who live in independent and assisted-living communities often self-administer a variety of supplements without telling their nurses or primary care providers. Nurses working in these settings need to talk with their residents about the safety and efficacy of CAM therapies. To prevent toxicities and supplement-drug interactions, encourage residents to inform the health care team about which supplements they are taking (Moquin et al., 2009).

In some cases, herbal preparations are self-administered to treat a serious health problem that could more effectively be treated by conventional medicine, potentially resulting in a delay of diagnosis and treatment. For example, patients may take St. John’s wort for depression rather than be evaluated for possible psychotherapy and/or drug therapy. In other cases, patients may neglect or choose not to tell their health care providers about their use of supplements. As a result, they may take conventional drugs and natural products to treat the same condition. The resulting drug-supplement interactions may be harmful or life threatening.

Nursing Safety Priority

Drug Alert

When caring for patients in any health care setting, ask them if they use herbs or nutritional supplements and, if so, for what purpose. Ask about the frequency and dose of the products used. To prevent complications, remind patients of the importance of telling all health care providers about dietary supplement or herbal therapy use. For example, to avoid increased risks of bleeding, one should not use ginkgo, ginseng, or garlic for at least 3 days before surgery. Table 2-2 lists several commonly used herbs, their uses, and their precautions. Teach patients about these precautions and how to safely use them.

TABLE 2-2

COMMONLY USED HERBAL PREPARATIONS: DESIRED EFFECTS AND PRECAUTIONS

HERB	DESIRED EFFECTS/USES	HEALTH TEACHING/PRECAUTIONS
Ginkgo biloba	Reduces memory problems, dementia, peripheral vascular disease; has antioxidant and vasodilator properties.	Use with anticoagulants may cause bleeding; rarely dizziness, headache, GI upset.
Garlic	Lowers cholesterol or blood pressure; acts as a natural antibiotic; acts as an antiplatelet agent.	Bleeding can occur when used with other antiplatelet agents; potentiates action of antidiabetic drugs; avoid several days before surgery.
Glucosamine sulfate	Decreases inflammation; effective for knee osteoarthritic pain.	Takes several weeks to be effective; monitor for increased INR in patients taking warfarin; can cause GI upset—take with meals.
Ginseng	Promotes general well-being; anti-aging.	Observe INR with warfarin. Side effects depend on type of ginseng used.
Saw palmetto	Decreases prostatic hyperplasia.	Discontinue 2 weeks before surgery because it inhibits platelet aggregation (clotting).

INR, International normalized ratio.

Caution patients about unreliable sources of health information, and refer them to credible resources for herbal remedies. Examples of excellent websites for accurate information are the Herb Research Foundation (www.herbs.org) and The National Center for Complementary and Alternative Medicine (www.nccam.nih.gov).

Probiotics, another commonly used group of products, are live microorganisms that are similar to those naturally found in the GI tract. When taken orally, these organisms colonize to enhance the immune response and stabilize the GI mucosal barrier. Most probiotics are bacteria that come from two groups—Lactobacillus and Bifidobacterium. Within each of these main groups are different species or strains. A few probiotics are yeasts.

Probiotics are available in foods and dietary supplements. Examples of foods containing probiotics are yogurt, miso, tempeh, and some soy and juice beverages. Dietary supplements include capsules, tablets, and powders. Patients use probiotics to treat antibiotic-associated diarrhea (AAD), irritable bowel syndrome, bladder and intestinal infections, and lactose intolerance (NCCAM, 2011e).

Research on the effectiveness of probiotics has been promising but sometimes conflicting. A recent meta-analysis of 10 randomized controlled trials on the role of Lactobacillus to prevent AAD reported that the risk for developing AAD was significantly lower when probiotics were compared with placebo usage (Kale-Pradhan et al., 2010). Additional studies are underway to determine the safety and effectiveness of other probiotic types and strains (Zarowitz, 2010).

Teach patients that side effects of probiotics include gas and bloating. Remind them to take the product with meals. As always, tell patients to check with their health care providers before taking these products and inform future providers that probiotics are being used.

Aromatherapy also uses natural products; it is one of the fastest growing complementary therapies. Clinical aromatherapy uses essential oils from various parts of plants and trees to enhance psychological and physical well-being. Essential oils may be applied in compresses, used in baths, or applied topically to the skin to stimulate the brain to decrease pain, improve mood, or enhance cognitive function.

Numerous oils can be used. For example, lavender and rose are two common oils that promote relaxation and sleep. Peppermint has been used for stimulation and to promote concentration. Sandalwood, jasmine, and lavender may improve mood in patients with depression (NCCAM, 2011b). Before using aromatherapy, assess the patient for any allergies and any negative associations with particular smells. Some aromas can cause nausea and vomiting. Essential oils are potent and need to be diluted before being applied topically.

NCLEX Examination Challenge