Essentials of Complementary and Alternative Medicine (June 1999)

Essentials of Complementary and Alternative Medicine (June 1999): by Wayne B. Jonas (Editor), Jeffrey S. Levin (Editor) By Lippincott, Williams & Wilkins
By OkDoKeY

Essentials of Complementary and Alternative Medicine
C
ONTENTS
Associate Editors
Dedication
Foreword
Preface
Acknowledgments
Contributors
PART I. THE SOCIAL AND SCIENTIFIC FOUNDATIONS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE
Introduction: Models of Medicine and Healing
Wayne B. Jonas, Jeffrey S. Levin
1. The History of Complementary and Alternative Medicine
James C. Whorton
2. The Physician and Complementary and Alternative Medicine
Ronald A. Chez, Wayne B. Jonas, David Eisenberg
3. Ethics at the Interface of Conventional and Complementary Medicine
Howard Brody, Janis M. Rygwelski, Michael D. Fetters
4. Evaluating Complementary and Alternative Medicine: The Balance of Rigor and Relevance
Klaus Linde, Wayne B. Jonas
5. How to Practice Evidence-Based Complementary and Alternative Medicine
Wayne B. Jonas, Klaus Linde, Harald Walach
PART II. THE SAFETY OF COMPLEMENTARY AND ALTERNATIVE MEDICINE PRODUCTS AND PRACTICES
Introduction: Evaluating the Safety of Complementary and Alternative Products and Practices
Wayne B. Jonas, Edzard Ernst
6. The Safety of Herbal Products
Peter A.G.M. De Smet
7. The Safety of Nonherbal Complementary Products
Peter A.G.M. De Smet
8. The Safety of Homeopathy
Wayne B. Jonas, Edzard Ernst
9. Adverse Effects of Acupuncture
Edzard Ernst
10. Adverse Effects of Spinal Manipulation
Edzard Ernst
PART III: OVERVIEWS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE SYSTEMS
Introduction: Common Aspects of Traditional Healing Systems Across Cultures
Stanley Krippner
11. Ayurvedic Medicine
D. Vasant Lad
12. Traditional Chinese Medicine
Lixing Lao
13. Native American Medicine
Ken “Bear Hawk” Cohen
14. Tibetan Medicine
Vladimir Badmaev
15. Chiropractic Medicine
Dana J. Lawrence
16. Osteopathy
Harold Goodman
17. Naturopathic Medicine
Michael T. Murray, Joseph E. Pizzorno
18. Holistic Nursing
Barbara Dossey
19. Medical Acupuncture
Joseph M. Helms
20. Phytomedicine
Tieraona Low Dog
21. Spiritual Healing
Daniel J. Benor
22. Massage Therapy
Tiffany Field
23. Qigong
Ching-Tse Lee and Ting Lei
24. Biofeedback Therapy
Judith A. Green, Robert Shellenberger
25. Hypnotherapy

Ian Wickramasekera
26. Behavioral Medicine
G. Randolph Schrodt, Jr., Allan Tasman
27. Orthomolecular Medicine and Megavitamin Therapy
Alan R. Gaby
28. Homeopathy
Edward H. Chapman
29. Nutritional Biotherapy
Keith I. Block
30. Meditation and Mindfulness
Michael J. Baime
Appendices
Appendix A. Organizations and Suggested Readings
Appendix B. Indications and Precautions Chart with Clinical Trials
Appendix C. Appellations
Appendix D. Glossary

A
CKNOWLEDGMENTS
This book is the result of many minds, hearts, and souls who have shared a vision of healing with me. It would not exist without them. It began when Lance Sholdt, 
then at the Uniformed Services University of the Health Sciences, asked if I would work with him to put together a course in complementary and alternative medicine 
for the medical students. His careful construction of this course helped us outline the contents of the book. This book is the brainchild of Jeff Levin. He was the first to 
suggest that a textbook like this was needed and could be written. His heartfelt work and attention to detail kept things moving when I was bogged down. Janette 
Carlucci is the soul of the book, managing both the special features and the day-to-day contact with the many authors. To her, a special thanks on this journey. Ron 
Chez provided a much needed balance for the book. He was always ready and willing to assist with a critical eye and keep us anchored to how this book could be of 
benefit for patients. I would also like to thank the editors, Jane Velker, Beth Goldner, and Joyce Murphy, for understanding the complexity of the topic and for a 
commitment to quality over deadlines. And Tim Hiscock for finally saying that we were going to press—ready or not. I would just as soon have worked another three 
years on it as finish.
WBJ
Many thanks are due to so many people whose hard work and dedication made this book possible. Wayne Jonas has already mentioned the staff at Lippincott 
Williams & Wilkins and his assistant, Janette Carlucci. My job would have been impossible without their tireless efforts. I must also thank Christine Boothroyd, my 
former secretary at Eastern Virginia Medical School. Christine coordinated all of my work on this book for nearly two years, and I am forever in her debt. My former 
department chairman, Dr. Terence C. Davies, also could not have been more supportive as I devoted considerable time to writing, editing, reviewing, and 
corresponding. Finally, thanks are due to Wayne for agreeing to tackle this project with me. At times, I imagine he, like me, must have wondered what in the world we 
had gotten ourselves into, but we somehow managed to complete our task. Wayne’s breadth of clinical knowledge in complementary and alternative medicine and his 
wisdom and expertise in matters related to this field are what really made this book possible.
JSL

C
ONTRIBUTORS
V
LADIMIR
 B
ADMAEV
, M.D., P
H
D.
Staten Island, New York
M
ICHAEL
 J. B
AIME
, M.D.
Division Chief
Department of General Internal Medicine
The Graduate Hospital
Assistant Professor
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
D
ANIEL
 J. B
ENOR
, M.D.
Author of Healing Research, Vols. I-IV
Vision Publications
Southfield, Michigan
K
EITH
 I. B
LOCK
, M.D.
Medical Director
Institute of Integrative Cancer Care
Evanston, Illinois
Clinical Assistant Professor
College of Medicine
University of Illinois
Chicago, Illinois
H
OWARD
 B
RODY
, M.D., P
H
D.
Professor
Departments of Family Practice and Philosophy
Michigan State University
Director
Center for Ethics and Humanities in the Life Sciences
East Lansing, Michigan
E
DWARD
 H. C
HAPMAN
, M.D., P
H
D.
Clinical Instructor
Harvard University School of Medicine
Boston, Massachusetts
R
ONALD
 A. C
HEZ
, M.D.
Professor of Obstetrics and Gynecology
Professor of Community and Family Health
University of South Florida
Tampa, Florida
K
ENNETH
 S. C
OHEN
, M.A., M.S.TH.
Adjunct Professor
Union Institute Graduate School
Cincinnati, Ohio
P
ETER
 A.G.M. D
E
 S
MET
, P
H
D.
Pharmaceutical Care Unit
Scientific Institute of Dutch Pharmacists
The Hague, The Netherlands
B
ARBARA
 D
OSSEY
, R.N., M.S., F.A.A.N.
Director
Holistic Nursing Consultants
Santa Fe, New Mexico
D
AVID
 E
ISENBERG
, M.D.
Assistant Professor of Medicine
Harvard Medical School
Director Center for Alternative
Medicine Research and Education
Beth Israel Deaconess Medical Center
Boston, Massachusetts
E
DZARD
 E
RNST
, M.D., P
H
D., F.R.C.P. (EDIN)
Professor and Director
Department of Complementary Medicine University of Exeter
Exeter, England
M
ICHAEL
 D. F
ETTERS
, M.D., M.P.H.
Assistant Professor
Department of Family Medicine
University of Michigan Health System
Director
Japanese Family Health Program
University of Michigan Health System
Ann Arbor, Michigan
T
IFFANY
 F
IELD
, P
H
D.
Director, Touch Research Institute
Nova/Southeastern University
Fort Lauderdale, Florida
A
LAN
 R. G
ABY
, M.D.
Professor of Nutrition
Bastyr University

Kenmore, Washington
H
AROLD
 G
OODMAN
, D.O.
Private Practice
Silver Spring, Maryland
J
UDITH
 A. G
REEN
, P
H
D.
Professor
Department of Psychology
Aims Community College
Co-director
Health Psychology Services, LLC
Greeley, Colorado
J
OSEPH
 M. H
ELMS
, M.D.
Private Practice
Berkeley, California
Chairman of Physician Acupuncture Training Programs
UCLA School of Medicine
Los Angeles, California
W
AYNE
 B. J
ONAS
, M.D.
Department of Family Practice
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Director (1995–1998)
Office of Alternative Medicine
National Institutes of Health
Bethesda, Maryland
S
TANLEY
 K
RIPPNER
, P
H
D.
Professor of Psychology
Saybrook Graduate School
San Francisco, California
D. V
ASANT
 L
AD
, B.A.M.S., M.A.S
C
.
The Ayurvedic Institute
Albuquerque, New Mexico
L
IXING
 L
AO
, P
H
D., L.A
C
Assistant Professor and Clinical Director
Department of Complementary Medicine
University of Maryland School of
Medicine
Baltimore, Maryland
Clinic Director
MD Institute of Traditional Chinese Medicine
Bethesda, Maryland
D
ANA
 J. L
AWRENCE
, D.C.
Professor of Chiropractic Practice
Director of Publications and Editorial
Review
National College of Chiropractic
Lombard, Illinois
C
HING
-T
SE
 L
EE
, P
H
D.
Professor, Department of Psychology
Brooklyn College of the City
University of New York
Brooklyn, New York
Visiting Scholar
Institute of Ethnology
Academia Sinica
Taipei, Taiwan
T
ING
 L
EI
, P
H
D.
Assistant Professor
Department of Social Science
Borough of Manhattan Community
College of the City University of New York
New York, New York
J
EFFREY
 S. L
EVIN
, P
H
D., M.P.H.
Senior Research Fellow
National Institute for Healthcare Research
Rockville, Maryland
President (1997–1998)
International Society for the Study of Subtle
Energies and Energy Medicine (ISSSEEM)
Golden, Colorado
G
EORGE
 T. L
EWITH
, M.A., D.M., M.R.C.P., M.R.C.G.P.
Partner
The Centre for the Study of Complementary Medicine and
Senior Research Fellow
University Medicine
University of Southampton School of Medicine
Southampton, Hampshire, United Kingdom
K
LAUS
 L
INDE
, M.D.
Muenchener

Modell-Research Center for Complementary Medicine
Department of Internal Medicine II
Technische Universitaet
Munich, Germany
T
IERAONA
 L
OW
 D
OG
, M.D., A.H.G.
Medical Director
Treehouse Center of Integrative Medicine
Medical Advisor
Quality Control & Standards
Materia Medica Group
Physician
Private Practice
Albuquerque, New Mexico
M
ICHAEL
 T. M
URRAY
, N.D.
Member, Board of Trustees and Faculty
Bastyr University
Kenmore, Washington
J
OSEPH
 E. P
IZZORNO
, J
R
., N.D.
President
Bastyr University
Kenmore, Washington
J
ANIS
 M. R
YGWELSKI
, M.D.
Assistant Professor
Department of Family Practice
Michigan State University
East Lansing, Michigan
G. R
ANDOLPH
 S
CHRODT
, Jr., M.D.
Associate Professor
Department of Psychiatry and Behavioral Sciences
University of Louisville School of Medicine
Medical Director
Behavioral Medicine Program
Norton Psychiatric Clinic
Louisville, Kentucky
R
OBERT
 S
HELLENBERGER
, P
H
D.
Licensed Psychologist
Chair of Psychology
Aims Community College
Co-Director
Health Psychology Service LLC
Greeley, Colorado
A
LLAN
 T
ASMAN
, M.D.
Professor and Chairman
Department of Psychiatry and Behavioral Sciences
University of Louisville School of Medicine
Louisville, Kentucky
H
ARALD
 W
ALACH
, P
H
D., Dipl. Psych.
Department of Psychology
University of Freiburg
Freiburg, Germany
J
AMES
 C. W
HORTON
, P
H
D.
Professor
Department of Medical History and Ethics
University of Washington School of Medicine
Seattle, Washington
I
AN
 W
ICKRAMASEKERA
, P
H
D., A.B.P.P., A.B.P.H.
Consulting Professor of Psychiatry
Stanford Medical School
Stanford, California
Professor of Family Medicine
Eastern Virginia Medical School
Norfolk, Virginia

T
HIS BOOK IS DEDICATED TO MY WIFE,
 S
USAN
 C
UNNINGHAM
 J
ONAS, WHOSE LOVE, WISDOM, AND SERVICE TO OTHERS IS AN EXAMPLE FOR US ALL.
WBJ
F
OR
 L
EA
 S
TEELE
 L
EVIN, MY BELOVED WIFE AND PARTNER
.
JSL

A
SSOCIATE
 E
DITORS
Brian Berman, M.D.
Associate Professor of Family Medicine
and Director
The Center for Complementary Medicine
University of Maryland
Complementary Medicine Program
Baltimore, Maryland
George T. Lewith, M.A., D.M., M.R.C.P., M.R.C.G.P.
The Centre for the Study of Complementary Medicine
Senior Research Fellow
University Medicine
University of Southampton School of Medicine
Southampton, Hampshire, UK
Dr. MED Klaus Linde
München Modell-Center for Complementary Medicine Research
Department of Internal Medicine II
Technische Universität
Munich, Germany
Joseph E. Pizzorno, Jr., N.D.
President
Bastyr University
Kenmore, Washington
Kichiro Tsutani, M.D., Ph.D.
Associate Professor
Department of Clinical Pharmacology
Division of Information Medicine
Medical Research Institute
Tokyo Medical and Dental University
Tokyo, Japan
Jean Watson, R.M., Ph.D., F.A.A.N.
Distinguished Professor of Nursing
Founder, Center for Human Caring
Endowed chair, Caring Science
University of Colorado Health Sciences Center
Denver, Colorado

F
OREWORD
The publication of Essentials of Complementary and Alternative Medicine, the first comprehensive textbook for physicians about these increasingly popular forms of 
medical treatment, is very timely. For the first time, information about the foundations of complementary and alternative medicine (CAM), the safety of CAM products 
and practices, and overviews of nearly two dozen CAM systems are available in one place.
The purpose of this textbook is to provide mainstream medical professionals useful and balanced information about CAM. The development of this type of book is an 
ambitious and difficult goal for several reasons. Many CAM systems are claimed to have special patient benefits not met by either conventional medicine or other 
CAM approaches. There are few unifying themes across these systems (other than the belief that there are unmet patient benefits outside of conventional medicine). 
Faced with these problems, the editors have sought the best individuals in these diverse areas and worked with them to produce a balanced and useful book 
developed specifically for physicians. In many areas of CAM, there is a history of long-term and vigorous antagonism with conventional medicine, as well as different 
educational standards, training, and practices. Also, the basic concepts of what constitutes sufficient evidence of safety and efficacy vary among CAM systems. 
Ultimately, the usefulness of this book will depend on its success in addressing these issues in an objective, pragmatic, and convincing way.
Why is it important to publish this textbook? The main reason is the compelling evidence that medicine has been changing both scientifically and culturally for several 
decades. Let us start with the changes in conventional medicine since World War II.
The medicine of my childhood in a small rural town in Virginia was very different from the conventional medicine of today. For example, my 80-year-old sister who had 
a heart attack was treated by removal of the clot and insertion of a stent; both she and her husband viewed the procedure on television, and she was up and walking 
the next day. In contrast, when my 59-year-old father suffered a heart attack over 50 years ago, medicine really had little to offer.
Although there are many reasons for these dramatic changes in medicine, the dominant force has been the emergence of exact sciences underlying medicine 
(whereas once they were viewed as “soft sciences”). The rewarding results have been an ever-increasing understanding of basic life processes. This understanding, 
in turn, has allowed novel and successful approaches to disease control.
However, the advancement of science-based medicine has a downside: science-based specialty medicine has become less personal and more costly. And, 
cost-containment efforts pay for procedures done, rather than time spent with patients. For these and other reasons, patients seek to augment the benefits of modern 
conventional medicine with CAM.
The initial striking evidence of the widespread use of CAM in the United States was reported by David Eisenberg and colleagues in the  New England Journal of 
Medicine in 1993. According to Eisenberg’s report, one in three Americans saw an alternative health care practitioner in 1990 (constituting more visits than to 
conventional primary care physicians), and they paid more than 10 billion dollars in out-of-pocket expenses for this care. In addition, patients did not tell their 
physicians of their use of CAM because they assumed the physicians would not be interested or would not approve. In a follow-up study now completed, the evidence 
of even greater use of CAM has been confirmed and is most striking: more than 40% of Americans currently use CAM (approaching European and Australian rates), 
and as much out-of-pocket money is spent for CAM care as is out-of-pocket money spent for all of conventional medicine. These facts confirm the need for readily 
available information to help physicians understand, evaluate, and address CAM treatments that their patients are receiving. This textbook will help them do that.
A significant change occurred when the United States Congress mandated the opening of the Office of Alternative Medicine (OAM) at the National Institutes of Health 
(NIH). Medical schools are now seeking research support from this source. Research findings supported by the OAM can be expected to meet the familiar standards 
of NIH. In addition to research, more than 70 medical schools have (or are planning) courses in CAM for their medical student curriculum. And, although future 
physicians and other conventional health care workers will be versed in the advantages and disadvantages of CAM, most of those now in practice need accurate 
information.
Both conventional medicine and CAM share similar concerns in several important areas. Both systems need always to be committed to eliminating fraudulent practice 
or practitioners who severely misguide desperately ill patients. Therefore, a complete section on safety is provided in this book. However, information about efficacy is 
likely the most needed. Over the last few decades, conventional medicine has relied increasing on highly disciplined experimental methods to arrive at the most 
reasonable conclusions about effective treatments. Even with complex, large-scale, double-blind, controlled clinical trials, the goal always is both to increase our 
understanding of life processes and to demonstrate a difference in health outcomes. NIH-supported studies of CAM share this approach. Yet, there is also interest in 
developing other methods for testing effectiveness. For example, in Germany and elsewhere, efforts are being made to collect and use carefully evidence of 
symptomatic and clinical improvement in patients with long-term problems. Demonstrating well-documented alleviation of troublesome chronic symptoms, improved 
function, and better quality of life in satisfied patients using CAM would interest both the CAM and conventional medical communities.
In summary, CAM is being used by large numbers of people who derive benefits they have not received from conventional medicine. NIH-sponsored research is 
exploring the underlying scientific mechanisms of these approaches as well as their clinical efficacy. Medical students are being educated in the advantages and 
disadvantages of CAM systems and modalities. This textbook has been crafted to serve the growing communities of professionals who need thorough and accurate 
information about CAM. A majority of the authors are MDs or PhDs who have taught in medical schools. Only time will tell how useful any new textbook will be, but this 
goal is timely and the effort is to be commended.
Emotions and opinions range widely on the subject of CAM, yet at such times it is well to remember the words of Thomas Jefferson: “We are not afraid to follow the 
truth wherever it may lead, nor to tolerate any error so long as reason is left free to combat it.”
Robert Marston, M.D.
Director, National Institutes of Health (1968–1973)

I
NTRODUCTION:
 M
ODELS OF
 M
EDICINE AND
 H
EALING
Essentials of Complementary and Alternative Medicine
I
NTRODUCTION:
 M
ODELS OF
 M
EDICINE AND
 H
EALING
 
Wayne B. Jonas and Jeffrey S. Levin
The Rising Interest in Complementary and Alternative Medicine
 
Public and Professional Adoption of CAM
 
Responding to CAM
Why is there Increasing Interest in CAM?
 
The Potential Benefits of CAM
 
The Potential Risks of CAM
 
Reasons for Supplementary Role of CAM
CAM and Standards of Evidence
Central Models of Etiology and Treatment in Medicine
 
The Use and “Specialization” of Central Models in Medicine
The Integration of CAM and Conventional Medicine
 
The Potential Risks of Integration
 
The Potential Benefits of Integration
 
Science and Healing
What Physicians Need to Know About CAM
Chapter References
P
HYSICIANS ARE FACED DAILY WITH DISEASE, ILLNESS, SUFFERING, AND DEATH. THE MEDICAL PROFESSION AIMS TO HELP CURE, TREAT, COMFORT, AND SAVE THE LIVES OF 
THOSE WHO SEEK HELP. MOST PHYSICIANS MUST ALSO PERSONALLY FACE ILLNESS AT SOME TIME IN THEIR LIVES OR CARE FOR A LOVED ONE WHO IS ILL. WHETHER 
PROFESSIONALLY, PERSONALLY, OR WITH FAMILY, WHEN ILLNESS COMES ALL PRACTITIONERS WANT BASICALLY THE SAME THING–RAPID, GENTLE TREATMENT THAT CAN 
CURE US OR AT LEAST ALLAY OUR FEARS AND ALLEVIATE OUR SUFFERING. IN 1996, AN INTERNATIONAL GROUP OF HEALTH SCHOLARS AND PRACTITIONERS RECLARIFIED THE 
TRADITIONAL GOALS OF ALL MEDICINE (
1
). THESE GOALS ARE:
1.
THE PREVENTION OF DISEASE AND INJURY AND PROMOTION AND MAINTENANCE OF HEALTH.
2.
THE RELIEF OF PAIN AND SUFFERING CAUSED BY MALADIES.
3.
THE CARE AND CURE OF THOSE WITH A MALADY, AND THE CARE OF THOSE WHO CANNOT BE CURED.
4.
THE AVOIDANCE OF PREMATURE DEATH AND THE PURSUIT OF A PEACEFUL DEATH.
IT IS TOWARD THESE GOALS, THEY URGED, THAT ALL MEDICAL EDUCATION, RESEARCH, PRACTICE AND HEALTH CARE DELIVERY SHOULD BE AIMED.
Despite these common goals, practitioners' responses to disease and illness are remarkably varied, and opinions about these differences in approach are often 
strongly held. Who we trust to our care, what we decide is the best treatment, how we evaluate success, and when we look for alternatives depend on many factors. 
These factors include how one understands the nature of health and disease, what is believed to have gone wrong and why, the type and strength of the evidence 
supporting various treatments, and who is consulted when obtaining help. In short, our choice of medical modalities depends on our  models and perceptions of the 
world, the preferences and values we share, and the believed benefit that may come from a certain treatment, system of practice, or individual. Even in an age of 
modern science when medical decisions can be made on a more objective basis than ever before, these decisions are a complex social process. To understand what 
shapes our behavior toward health care, we must carefully examine these social forces. The rise in interest and use of complementary and alternative medicine 
(CAM) reflects social changes in our models, values, and perceived benefit from modern health care practices in the last several decades.
THE RISING INTEREST IN COMPLEMENTARY AND ALTERNATIVE MEDICINE
Public and Professional Adoption of CAM
Two identical surveys of unconventional medicine use in the United States, one done in 1990 and the other in 1997, showed that during that time frame CAM use had 
increased from 34% to 42%. Visits to CAM practitioners went from 400 million to more than 600 million visits per year, and the amount spent on these practices rose 
from $14 billion to $27 billion–most of it not reimbursed (
2
). As increased use of the phrase of “integrated medicine” for the CAM field suggests, these practices are 
now being integrated into mainstream medicine. Over seventy-five medical schools have courses on CAM (
3
), hospitals are developing complementary and integrated 
medicine programs, health insurers are offering “expanded” benefits packages that include alternative medicine services (
4
), and biomedical research organizations 
are investing more into the investigation of these practices (
5
). The American Medical Association recently devoted an entire issue of each of their journals to CAM.
This rising interest in CAM reflects not only changing behaviors, but also changing needs and values in modern society. This includes changes in the psychosocial 
determinants of CAM use; the “normalization” of users over time; concepts of the body; the relationship among the growing “fitness” movement, aging “baby boomers,” 
and CAM; and the nature of both the therapeutic relationship and the health care preferences. Many complementary health care practices diffuse throughout society 
through health “networks” that increasingly determine therapeutic choices (
5a
).
Of note is that CAM practices, like most conventional practices, are adopted and normalized long before scientific evidence has established their safety and efficacy. 
A key difference in how this occurs, however, is that in conventional practice, procedures are usually introduced by professionalized bodies or industries rather than 
by the public (
6
). Adoption in complementary medicine has occurred in the opposite direction: the public adopts and seeks out these practices first, and health care 
professions and industries follow. This says something about the changing nature of public preferences and professional responsiveness to those preferences. It also 
predicts that new “unconventional” practices will arise in the future as current CAM groups become more “professionalized” themselves and are adopted into the 
mainstream. Thus, we will always need ways of addressing alternative practices responsibly.
Responding to CAM
The prominence and definition of unorthodox practices varies from generation to generation. With the development of scientific medicine and advances in treatment of 
acute and infectious disease in this century, interest in alternatives largely subsided. As the limitations of conventional medicine have become more obvious, interest 
in alternatives has risen. The medical and scientific response to claims of efficacy outside official medicine has a distinct pattern (
7
). Initially, orthodox groups either 
ignore these practices or attempt to undermine and suppress them by making them hard to access, by labeling them as quackery or pseudo-scientific, and by 
disciplining those that use them (
8
, 
9
 and 
10
). Later, if the influence of these practices grows, the mainstream community begins to examine them, find similarities with 
what they already do, and selectively adopt practices into conventional medicine that easily fit (
8
, 
9
) (see also 
Chapter 1
). Once these concepts are “integrated,” the 
groups that originally held them are then considered mainstream, and those left on the fringes are again ignored and persecuted until their influence rises. This 
pattern of wholesale marginalization, followed by rapid but selective adoption, results in almost continual conflict between differing “camps” and wide fluctuations in 
resources and attention devoted to these areas–producing what Thomas Kuhn called “revolutions” in science and medicine (
10
).
How can the mainstream scientific and medical community responsibly address the “unofficial,” “unorthodox,” “fringe,” and “alternative” on a less erratic, more regular, 
and more rational basis? Any approach must not completely ignore or attempt to eliminate important values, concepts, and activities that alternatives have to offer. At 
the same time it must not throw open medicine to dangerous practices that compromise the desirable quality and ethical and scientific standards in the conventional 
world. Any such process must create a space and provide resources whereby unconventional concepts and claims can officially be explored, developed, and 
accommodated. Given the diversity of concepts, languages, and perceptions about reality that these various systems hold, this process must intentionally incorporate 
methods for conflict resolution, knowledge management, and transparency (
11
, 
12
). Such a process must first systematically explore the reasons for alternative 
practices. It must then seek out the common, underlying concepts upon which change in both alternative and conventional practices can be based.
WHY IS THERE INCREASING INTEREST IN CAM?
The Potential Benefits of CAM

Many CAM practices have value for the way their practitioners manage health and disease. However, most of what is known about these practices comes from small 
clinical trials. For example, there is research showing the benefit of herbal products such as  ginkgo biloba for improving dementia due to circulation problems (
13
) and 
possibly Alzheimer's (
14
); saw palmetto and other herbal preparations for treating benign prostatic hypertrophy (
15
, 
16
); and garlic for preventing heart disease (
17
). 
Over 24 placebo-controlled trials have been done with hypericum (St. John's wort) and have shown that it effectively treats depression. For mild to moderate 
depression, hypericum appears to be equally effective as conventional antidepressants, yet produces fewer side effects and costs less (
18
). The scientific quality of 
many trials, however, is poor.
As credible research continues on CAM, expanded options for managing clinical conditions will arise. In arthritis, for example, there are controlled trials reporting 
improvement with homeopathy (
19
), acupuncture (
20
), vitamin and nutritional supplements (
21
), botanical products (
22
, 
23
), diet therapies (
24
), mind–body 
approaches (
25
), and manipulation (
26
). Collections of (mostly small) studies exist for many other conditions, such as heart disease, depression, asthma, and 
addictions. The Cochrane Collaboration (with assistance from the Research Council for Complementary Medicine in the United Kingdom) provides a continually 
updated list of randomized controlled trials in CAM. A summary of the number of controlled trials currently in that database by condition and modality is in Appendix 
(B) of this book. The database in available online through the NCCAM webpage and through the Cochrane Collaboration (see 
Chapter 5
). With increasingly better 
research, more options and more rational and optimal CAM treatments can be developed. A diversity of credible approaches to disease is something that the public 
increasingly seeks (
5a
, 
7
).
The Potential Risks of CAM
Safety concerns of unregulated products and practices are also an important area for concern. Despite the presence of potential benefits, the amount of research on 
CAM systems and practices is nonetheless quite small when compared with conventional medicine. For example, there are more than 20,000 randomized controlled 
trials cited in the National Library of Medicine's bibliographic database, MEDLINE, on conventional cancer treatments, but only about 50 on alternative cancer 
treatments. As public use of CAM increases, limited information on the safety and efficacy of most CAM treatments creates a potentially dangerous situation. Although 
practices such as acupuncture, homeopathy, and meditation are low-risk, they must be used by fully competent and licensed practitioners to avoid inappropriate 
application (
27
). Herbs, however, can contain powerful pharmacological substances that can be toxic and produce herb–drug interactions (
28
). Some of these 
products may be contaminated and made with poor quality control, especially if shipped from Asia and India (
29
).
Reasons for Supplementary Role of CAM
Patients use CAM practices for a variety of reasons. For example, use of alternative therapies may be normative behavior in their social networks; they may be 
dissatisfied with conventional care; and they may be attracted to CAM philosophies and health beliefs (
5a
, 
30
, 
31
). The overwhelming majority of those who use 
unconventional practices do so along with conventional medicine (
32
), thus corresponding to the implicit ideal of the phrase “complementary medicine.” CAM is truly 
“alternative”–that is, used exclusively–for less than 5% of the population (
31
). Further, contrary to some opinions within conventional medicine, studies have found 
that patients who use CAM do not generally do so because of antiscience or anticonventional-medicine sentiment, nor because they are disproportionately 
uneducated, poor, seriously ill, or neurotic (
30
, 
31
, 
33
, 
34
). Instead, several salient beliefs and attitudes motivating CAM and characterizing CAM users can be 
identified.
P
RAGMATISM
For the majority of patients, the choice to use unorthodox methods is largely pragmatic. They have a chronic disease for which orthodox medicine has been 
incomplete or unsatisfactory. Thus, we see many patients with chronic pain syndromes (low back pain, fibromyalgia, arthritis) or chronic and frequently fatal diseases 
(cancer, AIDS) seeking out CAM for supportive care (
2
, 
30
, 
30a
). An underlying characteristic of all of these conditions is that a specific cause of the disease either is 
unknown or cannot be stopped. Medical approaches did not work well with these conditions. Many CAM systems offer supportive care under these circumstances 
rather than addressing specific causes.
H
OLISM
CAM users are attracted to certain philosophies and health beliefs (
31
). In medicine, this philosophy is reflected in the desire for a “holistic” approach to the patient. In 
reality, all therapy, whether conventional or alternative, is holistic in the sense that the whole person always responds. Any intervention–drugs, surgery, 
psychotherapy, acupuncture, or herbal treatments–affects the entire body and mind. For patients, holism often means attending to the psychosocial aspects of illness. 
CAM practitioners spend more time addressing psychosocial issues, leaving patients more satisfied than with their visits to conventional practitioners (
35
). This 
perspective also emphasizes using health enhancement in the treatment of the disease, and being proactive in addressing early warning and life style factors that put 
patients at risk (
36
, 
36a
).
L
IFE
 S
TYLE
The emphasis on health promotion as an integral part of disease treatment is part of almost all CAM systems. Most of these systems use similar health enhancement 
approaches that cover five basic areas. These five areas are: a) stress management; b) spirituality and meaning issues (
37
); c) dietary and nutritional counseling; d) 
exercise and fitness; and e) addiction or habit management (especially tobacco and alcohol use) (
38
, 
38a
). All major CAM systems (and increasingly conventional 
approaches) make these areas primary in disease treatment (see chapters in