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Institute of Medicine (US) Committee on the Use of Complementary and Alternative Medicine by the American Public. Complementary and Alternative Medicine in the United States. Washington (DC): National Academies Press (US); 2005.

Cover of Complementary and Alternative Medicine in the United States

Complementary and Alternative Medicine in the United States.

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2Prevalence, 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 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:

TABLE 2-1. Use of Complementary/Alternative Medicine by U.S. Adults.

TABLE 2-1

Use of Complementary/Alternative Medicine by U.S. Adults.

  • 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 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, 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.

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, 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 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 socio-demographic 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.

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 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 discussed possible explanations. Like other national surveys, CAM is not defined consistently among surveys. This particular survey asked whether a CAM provider was consulted in the previous year, which does not take into account the use of self-prescribed therapies, such as dietary supplements.

TYPES OF ILLNESS

Studies of the use of CAM for the treatment of specific illnesses have documented the popularity of CAM for the treatment of health problems that lack definitive cures; that have an unpredictable course and prognosis; and that are associated with substantial pain, discomfort, or side effects from prescription drug medicine. For example, back pain/back problem was the most common condition (16.8 percent) identified in the 2002 NHIS (Barnes et al., 2004). CAM use has been identified as particularly common among women suffering from the symptoms of menopause (Beal, 1998; Cherrington et al., 2003; Kronenberg and Fugh-Berman, 2002) and pregnancy-related illnesses (Tiran, 2002), gynecology problems (von Gruenigen et al., 2001), rheumatology problems (Rao et al., 1999; Wootton and Sparber, 2001c), gastroenterological diseases (Rawsthorne et al., 1999), rhinosinusitis (Krouse and Krouse, 1999), attention and hyperactivity problems (Chan et al., 2003), psychiatric and neurological problems (Sparber and Wootton, 2002), cancer (Adler, 1999; Bernstein and Grasso, 2001; Burstein et al., 1999; Henderson and Donatelle, 2004; Kao and Devine, 2000; Lee et al., 2002; Lee et al., 2000b; Lengacher et al., 2002; Patterson et al., 2002; Richardson et al., 2000, Sparber and Wootton, 2001; Sparber et al., 2000; Swisher et al., 2002; VandeCreek et al., 1999; Wilkinson et al., 2002; Zimmerman and Thompson, 2002), HIV/AIDS (Fairfield et al., 1998; Wootton and Sparber, 2001b), asthma (Braganza et al., 2003), and disabilities (Krauss et al., 1998). Still other studies have examined the prevalence of patients who use CAM in various types of nonspecialty clinics such as pediatric clinics (Davis and Darden, 2003; Madsen et al., 2003; Sawni-Sikand et al., 2002), primary-care clinics (Gordon et al., 1998; Kitai et al., 1998), maternity practices (Hepner et al., 2002), emergency rooms (Gulla and Singer, 2000; Rogers et al., 2001; Weiss et al., 2001), and postsurgery clinics (Norred et al., 2000). One reason for conducting such studies has been to identify possible CAM-conventional medicine interactions, especially in cases in which it is vital to a patient's well-being to know of medications that may interfere with such things as blood clotting time when surgery is being performed (Allaire et al., 2000; Hepner et al., 2002) or with other conventional practices that have been taken or have been prescribed by CAM practitioners or midwives.

These examples are not meant to be exhaustive but, rather, representative of the range of studies that have used various sampling techniques and that have been performed with particular U.S. patient populations over the past decade. These surveys confirm the impression that a significant percentage of individuals with chronic or life-threatening illnesses are using CAM at some point during the course of their illness.

More difficult to discern are an individual's reasons for using a CAM modality at a particular point in time over the course of an illness. One cannot tell from survey data whether those surveyed used a CAM modality primarily for curative purposes or primarily for a specific health problem, as a means of reducing the side effects from other types of therapy, or for general health-promoting purposes. Nor can it be determined which type of therapy (conventional or CAM) was sought first. It is worth noting that for many of the chronic conditions listed above, management of patients' health care needs includes but extends beyond the management of overt symptoms associated with the disease. The importance of this observation may be considered in light of studies on health care expenditures associated with chronic disease. It has been estimated that more than 45 percent of noninstitutionalized Americans have one or more chronic conditions and their direct health care costs account for 75 percent of U.S. health care expenditures (Hoffman et al., 1996).

Using a nationally representative sample of 23,230 U.S. residents, Druss et al. (2001) calculated that half of U.S. health care costs in 1996 were borne by persons with one or more of five conditions: mood disorders, diabetes, heart disease, asthma, and hypertension. Notably, of that amount, only about one-quarter was spent on treating the conditions themselves; the remainder was spent on treating coexistent illnesses and health care problems. Those researchers pointed out that each condition was associated with unique patterns of health service use driving those costs. This finding highlights the need for a better understanding of what motivates patients with chronic complaints to seek both CAM and conventional medical services and the cost implications of combined care. In other words, does utilization of CAM reduce or increase the costs of health care for people with different types of chronic conditions?

FREQUENCY OF USE

Wolsko and colleagues (2002), using the database of Eisenberg et al. (1998), evaluated the extent to which high-frequency users of CAM contributed to the total number of visits to CAM providers. Notably, they found that individuals who saw conventional health care providers more frequently were also the most apt to use complementary care services. Conservative extrapolation to national estimates suggested that a small fraction of U.S. adults (8.9 percent) accounted for 20 percent of CAM users but that they made more than 75 percent of the 629 million visits to CAM providers. These data parallel observations that a large percentage of the annual U.S. health care budget is routinely consumed by a relatively small percentage of the U.S. population. CAM services can and should be viewed similarly. Notably, however, high-frequency users of biomedicine and high-frequency users of CAM appear to use these modalities for different purposes. Additionally, Druss and Rosenheck (1999) point to a difference between these two populations of high-frequency users: psychiatric disorders are prominent among the high-frequency users of conventional medicine, but the researchers found no such correlate among high-frequency users of CAM modalities.

Wolsko and colleagues (2002) also examined the extent to which insurance coverage was independently associated with CAM therapy use. They found that for individuals who sought the services of practitioners who performed physical manipulation (e.g., chiropractors and massage therapists), full insurance coverage, partial insurance coverage, and the use of the therapy for wellness were all associated with the high-frequency use of such providers. Among the survey respondents using the services of CAM providers, 63 percent of those reporting that they had full insurance coverage made eight or more visits to a CAM practitioner during the previous year. Only 17 percent of those reporting that they had no insurance coverage made eight or more visits. For CAM therapies which were not related to physical manipulation (e.g., relaxation therapy and advice regarding herbs supplements), the only factor associated with high-frequency provider use was having used the therapy for wellness. Having any insurance coverage, it appears, is associated with higher rates of use of CAM therapy services. Rates of insurance coverage for CAM services varies significantly by state, treatment plan, and CAM modality (Tillman, 2002). The services of chiropractors are covered by between 41 and 65 percent of health maintenance organizations (HMOs), the services of homeopaths are covered by 4 to 11 percent of HMOs, acupuncture is covered by 9 to 19 percent of HMOs, and massage therapy is covered by 6 to 10 percent of HMOs (Stanger and Coughlan, 2000). Depending on the therapy, Eisenberg et al. (1998) also found various rates of partial and full coverage, with only four modalities (chiropractic, megavitamins, imagery, and biofeedback) receiving some form of coverage more than 50 percent of the time.

LONG-TERM TRENDS IN CAM USE

What are the long-term trends in CAM use likely to be and how do they differ from the trends experienced earlier in history? Kessler and colleagues (2001) analyzed the same dataset obtained by Eisenberg et al. (1998) in their 1997 survey, but focused on questions about first-time use of CAM therapies by all individuals aged 18 and older. They observed that 68 percent of all respondents had used as least one CAM therapy during the course of their lives. Lifetime use steadily increased with age across all age cohorts. Specifically, individuals in the pre-baby boom cohort (i.e., older than age 58 years at the time of the survey) had a 30 percent incidence of CAM therapy use by the age of 33; 5 of 10 baby boomers had used one or more CAM therapies by age 33, and 7 of 10 individuals born after the baby boom reported the use of some type of CAM therapy by age 33. It was also noted that prior use of any CAM therapy was an excellent predictor of current use. Among the respondents who had ever used a CAM therapy, roughly half continued to use a CAM therapy many years later (during the interval of the survey).

These analyses also documented the fact that the rate of use of all but 4 of the 20 most commonly used complementary therapies increased in frequency beginning in the 1960s. During the decades of the 1970s, 1980s, and 1990s, the use of particular CAM therapies increased at higher rates than the use of others. For instance, the 1970s witnessed large increases in the rates of use of herbal medicine, imagery, energy healing and biofeedback, whereas in the 1980s the rates of use of massage therapy and naturopathy increased most rapidly.

Kessler and colleagues (2001) mention that “from an historical perspective, data from 1998 may not necessarily represent a consistent trend of increased use of CAM therapies, but rather a distinct peak in a long trend of constant fluctuation in complementary and alternative medicine use by the American public.” They refer to previous peaks of CAM use such as survey data from the 1920s and 1930s indicating high rates of use of “unconventional” therapies and government statistics from 1900 documenting large numbers of registered “alternative” practitioners. Kessler et al. conclude that the recent high rates of CAM use may in fact be demonstrating a resurgence of CAM use after a period of diminished use during the 1940s and 50s. Even so, use of CAM therapies in recent years by a large proportion of the U.S. population is seen as a result of a historical trend that began at least 50 years ago. Moreover, this trend suggests a continuing demand for CAM therapies that will affect health care delivery for the foreseeable future.

Other factors associated with CAM therapy use that further this hypothesis include the observation that CAM therapies are used predominantly for the treatment of chronic disease, which, as mentioned above, accounts for an increasing fraction of the U.S. healthcare burden (Astin, 1998). In addition, an estimated one-third of CAM therapy use is attributed to disease prevention and health promotion (Eisenberg et al., 1993, 1998). These patterns parallel trends in U.S. society to promote disease prevention and to encourage health promotion, especially among those in the baby boom generation, 50 percent of whom already use CAM therapies, usually in the absence of a chronic or a disabling disease. As such, CAM use is quite likely to increase in the coming quarter century as the baby boom generation experiences greater disease burdens. Lastly, the observation that 7 of 10 individuals born after the baby boom generation routinely use CAM therapies by the age of 33 (Kessler et al., 2001) suggests that the U.S. public increasingly views CAM therapies as accessible options and “conventional” lifestyle choices that can no longer be viewed as entirely “alternative” practices.

COST-EFFECTIVENESS

CAM therapies are typically not centered on high-technology interventions and instead include low-cost treatments. This is often offered in support of the idea that CAM may provide more cost-effective treatments than conventional medicine. However, some CAM interventions involve more time with a practitioner, which may be costly (White and Ernst, 2000). Despite the claim that CAM is more cost-effective, there is not a large body of literature that explores the question of cost. White and Ernst (2000) conducted a review of cost description, cost comparison, cost-effectiveness, and cost-benefit studies. The studies in the articles reviewed tended to take two general approaches: evaluation of the cost of a specific therapy and health condition and examination of overall effects, such as rates and total health care costs. With a few exceptions, White and Ernst did not find a rigorous body of economic analyses for CAM. They offer several explanations, including the “intangible and indirect” benefits of CAM, such as patient preference, patient empowerment, and quality of life, as well as the cumulative benefits conveyed through lifestyle changes.

Since the review of White and Ernst (2000) was published, a few more economic evaluations of CAM have been published. Sobel (2000) reviewed four examples of mind-body interventions that demonstrated beneficial effects on health and cost-savings for heart disease, chronic disease, surgery, and prematurity among infants. For chronic low back pain, Cherkin et al. (2001) compared the effectiveness of acupuncture, massage, and self-care education. At the 1-year follow-up, patients randomized to receive therapeutic massage reported fewer symptoms than acupuncture recipients, and massage recipients used fewer medications than the other two groups. Finally, follow-up costs for outpatient HMO back care were lower for the massage group than for the acupuncture or the education group, although the difference was not statistically significant. An important limitation of this study was the lack of a no-treatment comparison group.

The treatment of chronic headaches with acupuncture was the subject of a recent randomized clinical trial and cost-effectiveness analysis by Wonderling and colleagues (2004) in the United Kingdom. Compared with usual care, acupuncture increased both quality-adjusted life years3 and health care costs. However, the investigators noted that the cost increase is less than that of another National Health Service-recommended medication for the treatment of migraine headaches. A second randomized controlled trial paired with an economic analysis, conducted in The Netherlands, examined the treatment of neck pain with physiotherapy, manual therapy, and general practitioner care (Korthals-de Bos et al., 2003). At 26 weeks, manual therapy led to a faster recovery. Additionally, at the 1-year follow-up, the analysis showed that manual therapy (i.e., spinal mobilization) cost less and was more effective than physiotherapy (i.e., mainly exercise) or general care (i.e., counseling, education, and medication). It should be emphasized that few studies of the cost-effectiveness of CAM therapies have been undertaken.

WHAT MOTIVATES PEOPLE TO USE CAM

Survey techniques are useful for finding out the personal and demographic characteristics of people who have tried CAM modalities, the point prevalence rate of people who have used CAM over specified periods of time (ever, last year, etc.), how much they have spent on these modalities, where they have received therapy (if they saw a CAM practitioner) or if they have engaged in self-treatment, and whether they have informed their conventional medical doctor that they are using CAM therapies or modalities (or whether they have informed their CAM practitioner that they are receiving biomedical treatments). They are far less useful as a means of providing information about people's motivations for using CAM therapies or modalities, given that rationale and rationalization are hard to tease apart on a survey and given that the reasons for using CAM use change over time, are complex, and are multidimensional.

A wide variety of motivations for using CAM have been reported in the literature dispelling any simple characterization of why the American public uses CAM therapies and modalities. Table 2-2 identifies many of the motivations for the use of CAM that have been identified in the health, social science, and CAM literature (Astin, 1998; Easthope, 1986; Foote-Ardah, 2003; Furnham and Forey, 1994; Furnham and Smith, 1988; Henderson and Donatelle, 2004; Kaptchuck and Eisenberg, 1998; Kelner and Wellman, 1997; Lloyd et al., 1993; Mitchell and Cormack, 1998; Sharma, 1992, 1996; Siahpush, 1999; Sirois and Glick, 2002; Sollner et al., 2000; Thorne et al., 2002).

TABLE 2-2. Reasons Why Different Types of People Use CAM Modalities at Different Points in Their Lives.

TABLE 2-2

Reasons Why Different Types of People Use CAM Modalities at Different Points in Their Lives.

An important finding noted by Wolsko et al. (2002) was that among the 2,055 study participants, the pursuit of wellness was a major contributor to CAM use. Those who used CAM for wellness purposes frequented CAM providers more often than those who did not. Other researchers have also noted that interest in health promotion and disease prevention appears to be a motivating force driving CAM use (Astin, 1998). Research suggests that obtaining “wellness care” from conventional and CAM providers is important to CAM users. Druss and Rosenheck (1999) found that adults who visit both CAM providers and conventional providers are more likely than individuals who seek care only from conventional providers to report that they monitor their blood pressure and cholesterol levels and undertake timely prostate and breast cancer screenings.

Astin and colleagues (2000) surveyed enrollees in a Medicare supplement plan offering benefits for selected CAM therapies and found that the most frequently cited reason for CAM use was “general health improvement” (42 percent), whereas CAM use for “chronic medical problems” was cited by only 18 percent of those surveyed. These findings are consistent with the findings of Eisenberg et al. (1993, 1998), who documented that 58 percent of those surveyed used CAM therapies, at least in part, to “prevent future illness from occurring or to maintain health and vitality,” whereas only 42 percent of those surveyed used CAM exclusively to treat an existing disease.

The 2002 NHIS asked participants about their reasons for using CAM. For any type of CAM, 54.9 percent believed that CAM therapy combined with conventional medical treatments would help, 50.1 percent thought that CAM would be interesting to try and 25.8 percent indicated that CAM use was suggested by a conventional medical professional. Alternatively, 27.7 percent believed that conventional medical treatments would not help, and 13.2 percent believed that conventional medical therapies were too expensive (Barnes et al., 2004).

Once a patient begins to use CAM therapies, however, how likely is the patient to continue to use them? Cross-sectional surveys carried out after time lapses of some years allow investigators to speculate about continued use for some purpose, be it health promotion, the treatment of periodic illness, or the management of a chronic illness or disability. Kessler et al. (2001) found that 50 percent of all CAM therapy use that had been initiated at least 5 years prior to the interview (Eisenberg et al., 1998) persisted at the time of the interview. This suggests that prior use of CAM therapy is a predictor of ongoing or current use for half of all users. The data also suggest that the persistent use of CAM therapies and modalities may be related to general health and may not be reserved only for the treatment of a particular time-limited ailment. This is consistent with the findings of Astin (1998) that most CAM therapies are used, at least in part, to prevent future illness or to maintain health and vitality as part of lifestyle choices linked to disease prevention and health promotion.

Further investigation into the association between the use of CAM modalities and wellness-related behavior is warranted given national public health priorities and the burden of lifestyle-related diseases (DHHS, 2000). What remains unknown is the extent to which different types and levels of CAM use foster or sustain behavioral changes contributing to positive health outcomes. CAM use may be a marker of “packages” of lifestyle changes associated with shifts in identity, or it may constitute little more than an attempt at harm reduction engaged by those who wish to minimize the negative effects of an unhealthy environment, job, or lifestyle (Nichter, 2003). Data on wellness from existing cross-sectional surveys point out the need for long-term longitudinal cohort studies examining large numbers of adults who are routinely asked questions about CAM use as well as diet, exercise, smoking, etc. Such studies, reminiscent of the Framingham Heart Study or the Nurses' Health Study (both of which are ongoing and which could, conceivably, be expanded to include questions about CAM use) may offer the best opportunity to explore patterns of CAM use over time as well as the role—or lack thereof—of CAM in promoting health, reducing risk, and preventing disease.

One hypothesis for why people use CAM is that they are dissatisfied with conventional care. The literature suggests that this is not most user's primary reason for CAM use (Astin, 1998; Barnes et al., 2004; Eisenberg et al., 2001). Users of CAM often use CAM modalities simultaneously with conventional medicine when they are ill. They typically (70 percent) use CAM subsequent to or simultaneously with the use of conventional medicine, and 79 percent of respondents who saw a medical doctor and used CAM therapies perceived the combination to be superior to either one alone (Eisenberg et al., 2001). A second hypothesis is that CAM users maintain health beliefs different from those of other people, but an answer to this question will require investigation of health perceptions before and after CAM use to determine whether users sought CAM modalities on the basis of their health ideology or underwent transformational experiences.

Astin (1998) conducted the only national survey on personal factors that predispose individuals to use CAM. He found that higher levels of education, a transformational experience that changed one's world view, a holistic health philosophy, and interest in alternative lifestyles were determinants of CAM use. Other studies have also documented an association between CAM use and a holistic (e.g., New Age) health philosophy (Easthope et al., 2000; Furnham and Forey, 1994; Pawluch et al., 2000; Sharma, 1993). Although embracing such a philosophy is undoubtedly a factor related to sustained CAM use by many people, it is most likely not the initial motivation for many others to seek care from CAM practitioners or to use CAM-related resources (Kelner and Wellman, 1997).

The research summarized in Table 2-2 suggests that people seek CAM modalities for a wide variety of reasons. Some of those attracted to CAM modalities seek a therapeutic relationship with a practitioner in which they have the opportunity to more fully participate in their own health care decision making (Mitchell and Cormack, 1998). For example, cancer patients vary considerably in their preference for participation in decision making. While some of those who wish to share responsibility for care find preferred relationships with practitioners of conventional medicine, many others do not (Arora, 2003). Many who use CAM as supplementary care do so as a way of avoiding passivity and coping with feelings of hopelessness. It might be more productive to investigate the extent to which these individuals are simply trying to marshal all resources at their disposal toward the end of securing optimal health care, a concept that is relative and subject to interpretation in accord with a patient's needs and expectations.

For many people, all forms of health care are options, alternatives to be exploited in an everexpanding health care arena subject to market forces, scientific evolution, and the vagaries of public opinion. Many CAM users access different forms of health care from different places with limited if any coordination between practitioners or knowledge being shared about the eclectic therapies used or medicines taken. Lack of coordination is far from ideal. Research needs to address the multiple factors motivating health care seeking in the pluralistic health care arena that exists at present and the use of eclectic health care resources by the American public.

One problem with general characterizations of why people use CAM is that such representations overlook different motivations for initiating CAM and sustaining CAM use over time. They also generate stereotypes about CAM and conventional practitioners that are simplistic and not borne out by the evidence. Figure 2-1 summarizes information from a nationally representative sample on how dual users of CAM and conventional medicine compare these two broad types of health care and their interactions with both types of care providers. Figure 2-1 depicts a very mixed picture of how users of CAM feel about their practitioners (Eisenberg et al., 1998).

FIGURE 2.1. Users' comparison of CAM and conventional health care.

FIGURE 2.1

Users' comparison of CAM and conventional health care. NOTE: * Asked of respondents who had seen a medical doctor and used any CAM therapies (including use of self prayer alone) in the past 12 months. Asked of respondents who had seen both CAM (more...)

Motivations for using CAM change over time and are influenced by many potentially important intervening variables: frustrations with existing therapies, a desire to try something new, changes in the meaning that one attributes to one's ailment, changes in self-identity associated with CAM use, the economics of receiving care, and the feedback that one receives from significant others who form an individual's therapy management support group. The user types highlighted in Table 2-2 represent a heuristic. Real users of CAM are likely to approximate different ideal types at different points in their lives as well as to be influenced by multiple motivations to use CAM at any one time.

Sirois and Gick (2002) have recently called for a more sophisticated way of looking at CAM users that does not treat them as a homogeneous group with similar beliefs, motivations, and needs and that attends to how their behaviors change over time. They conducted one of the few studies to explore differences in the reasons for using CAM among two groups of CAM users, defined by the length and frequency of CAM use, and a comparison group of users of conventional medicine. New or infrequent CAM users, established CAM users, and users of conventional medicine were distinguished on the basis of health beliefs and sociodemographic, medical, and personality variables. Different patterns of predictors of CAM use for the different groups emerged. In general, health-aware behaviors and dissatisfaction with conventional medicine were the best predictors of overall and initial or infrequent CAM use, while more frequent health-aware behaviors were associated with continued CAM use. Medical need also influenced the choice to use CAM and was the best predictor of committed CAM use, with the established CAM users reporting more health problems than the group of new or infrequent CAM users. An openness to new experiences was associated with CAM use, most notably in the decision to initially try or explore the use of CAM. In a further analysis of their data, Sirois (2002) found that newer CAM users still relied heavily on conventional medical treatments, whereas more experienced CAM users depended less on CAM alone and more on CAM for the treatment of their non-life-threatening health problems.

ACCESSING INFORMATION ABOUT CAM

Little research has been carried out to investigate

  • Where the public goes to search for information about CAM modalities
  • What sources of information they commonly find and access
  • The effect of CAM advertising on health care seeking behavior
  • What types of the information are deemed credible, marginal, and spurious
  • How risks and benefits are understood and how such perceptions inform decision making
  • What the public expects their providers to tell them

Information about CAM modalities appears to be obtained in three major ways. First, it has widely been reported that information about CAM is often spread by word of mouth within social networks and that referral by lay individuals is common. However, the committee found no study that investigated the impact of one person's CAM involvement on that person's immediate family or larger social network. Analysis of CAM use among those afflicted with particular health problems and those engaging in promotive health activities associated with CAM is needed.

The second source of information is the Internet. It is known that a significant percentage of the American public conducts Internet-based searches to find information about health problems and potential treatments. A recent study estimated that 73 million Americans, or 62 percent of Americans with access to the Internet at the time, have used the Internet to search for information related to health care (Fox and Rainie, 2002). Of these health information seekers, 92 percent reported that the information that they obtained during their last Internet search was useful and relevant (Fox et al., 2000), and 68 percent indicated that it had some role in their health care decision making (Fox and Rainie, 2002). It is reasonable to assume that many of those contemplating or already using CAM modalities access the Internet to find out about these modalities.

A few studies have been conducted to determine what a hypothetical health seeker might find on the Internet were he or she to search for common herbal medications. Morris and Avorn (2003) searched the Internet using the five most commonly used search engines and examined what surfaced when they entered the names of the eight most widely used herbal supplements (Ginkgo biloba, St. John's wort, echinacea, ginseng, garlic, saw palmetto, kava kava, and valerian root). The health content of all websites listed on the first page of the search results were analyzed for a total of 443 sites that met study inclusion criteria. Among the 443 websites, 338 (76 percent) were retail sites. Eighty-one percent of these retail websites made one or more health claims; of these, 149 (55 percent) claimed to treat, prevent, diagnose, or cure specific diseases. More than one-half (153 of 292; 52 percent) of the sites with a health claim omitted the standard federal disclaimer. Bonakdar (2002) conducted a disease-specific search for herbal drugs for cancer. A majority of sites examined claimed that they offered cures for cancer through herbal supplementation with little regard for federal regulations against doing so, with such claims being more common on sites operated from outside the United States.

Ashar and colleagues (2003) conducted a third study that evaluated information contained within Internet sites that advertise and market dietary supplements containing ephedra. Thirty-two products and advertisements were identified and systematically evaluated for deviance from truth-in-advertising standards. Of the 32 websites analyzed, 13 (41 percent) failed to disclose potential adverse effects or contraindications to supplement use. Seventeen (53 percent) did not reveal the recommended dosage of ephedra alkaloids. More importantly, 11 sites (34 percent) contained incorrect or misleading statements, some of which could directly result in serious harm to consumers. These and other studies (Matthews et al., 2003; Sagaram et al., 2002) illustrate that consumers are commonly misled by vendors' claims that herbal products can treat, prevent, diagnose, or cure specific diseases, despite regulations prohibiting such statements. Closer monitoring of web sites, enforcement of the Dietary Supplement Health and Education Act of 1994 (DSHEA) and Federal Trade Commission regulations, and the creation of a user-friendly authoritative website or criteria for evaluating existing websites on CAM modalities are much needed.

A third common source of information about CAM-related modalities is health food stores. A handful of surrogate patient studies have been conducted in which a researcher poses as a prospective client and asks for advice about what type of herbal medicine he or she (or a family member) should take for a specified ailment. In one study conducted by Mills et al. (2003), eight data gatherers asked employees of all retail health food stores in a major Canadian city what they recommended for a patient with breast cancer. The data gatherers inquired about product safety, potential drug interactions, cost, and efficacy. Employees at 34 stores were queried, and a total of 33 different products were recommended. Twenty-three employees (68 percent) did not ask whether the patient took prescription medications, 15 employees (44 percent) recommended visiting some type of health care professional, and only 3 employees (8.8 percent) discussed the potential adverse effects of the products.

In another study, Glisson et al. (2003) investigated what products health food store employees recommended for the treatment of depression and how they explained the benefits and risks. Twelve health food stores in the United States were selected for the study. An investigator approached an employee in each store and asked what he or she recommended for depression plus five additional questions regarding product use. All 12 health food store employees recommended a St. John's wort supplement for the treatment of depression. The employees made numerous comments about St. John's wort and its use for treatment of depression that were unsafe and inaccurate. Notably, that study and another study of shopkeeper recommendations for medications for children with Crohn's disease (Calder et al., 2000) found that health food store employees tend to refer to a common resource when making recommendations. If this is a widespread practice, the availability of public access to a website recognized by health food store employees as authoritative might enhance the therapeutic advice given and minimize the potential for dangerous errors to be made when they offer information, especially if the customer was asked to indicate other medications taken at the time.

HOW THE AMERICAN PUBLIC USES CAM MODALITIES

Although reliable data exist on the percentage of people who have used a CAM modality in the last year and how many times the modality was used in general, far less is known about the reasons for CAM use at various times. Existing surveys also provide little information about what proportions of CAM use are

  • 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 [massage, acupuncture, chiropractic] to me.”
  • 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 X [herbs, self hypnosis, yoga, etc.].”

Little is known about how individual patients actually use CAM modalities while they are under the care of a CAM practitioner or engaging in self-treatment. The committee was not able to find a single scientific study to date on the rates of compliance or adherence to CAM therapies or supplements purchased over the counter. This stands in stark contrast to a rather robust literature on adherence in conventional medicine (DiMatteo et al., 2002; Donovan and Blake, 1992; Vermeire et al., 2001), a search for which on the PubMed website conducted in December 2003 yielded more than 50,000 citations.

Further, we have no information about whether or the extent to which use of a CAM therapy may interfere with compliance in the use of conventional therapies. Having no information about the extent to which patients using CAM adhere to guidelines or directions for treatment produces a major gap in our knowledge. We do not know if patients are using products as directed or even for the purpose recommended. Such information is important, not because we want to assure that patients “follow orders,” but rather to assure that patients are using products and therapies safely and effectively. Even if a therapy is efficacious, it may have little or no effect if it is taken or used incorrectly. Indeed, medicines and other CAM products and procedures may be the source of iatrogenic health problems if they are used incorrectly. It has been routinely observed that a significant proportion of those who take conventional medicine are noncomplaint for a host of reasons. Nonadherence to treatment guidelines may be just as common in the case of CAM. Indeed, patients who believe that herbal medicines are harmless may be more willing to self-regulate their medication in unsupervised ways.

Studies of adherence to dietary supplements pose a special challenge. Because of government regulations (DSHEA), supplement labels are not allowed to make claims about the treatment for named illnesses, although they are commonly used for this purpose. Instructions on packages are therefore written to address complaints according to “structure and function” guidelines (see Chapter 9). At issue is whether users are following the printed instructions or are using these “medicines” for other purposes. On the other hand, are they seeking information on how to use supplements from other sources? On the basis of what criteria can compliance be ascertained? A lack of data on compliance is a major oversight in current CAM research.

Use of CAM in Supervised, Unsupervised, and Eclectic Ways

Unlike many conventional approaches to health care (e.g., prescription medications, surgical procedures, chemotherapy, and radiation), some CAM therapies are provided by licensed practitioners (e.g., acupuncturists, chiropractors, and massage therapists); others are provided by practitioners or are used by individuals without professional supervision (e.g., meditation and relaxation techniques, dietary supplementation, and dietary modification) and some forms are used without professional supervision altogether. As reported by Eisenberg et al. (1993), in 1990 nearly half (47 percent) of respondents who used one or more CAM therapies for their principal medical conditions did so without any professional supervision, that is, without either visiting a CAM practitioner or discussing their CAM therapy with their medical doctor.

It is also known that individuals who use CAM therapies tend to do so rather eclectically and in complex ways. Wolsko et al. (2002) reported that among individuals who used one or more CAM therapies in 1998, 46 percent used one therapy, 20 percent used two therapies, 13 percent used three therapies, 7 percent used four therapies, 5 percent used five therapies, 3 percent used six therapies, and 5.5 percent used seven or more therapies. Of the respondents who used CAM therapies during the prior 12 months, an estimated 48 percent used only self-care-centered CAM modalities, whereas 52 percent had seen a CAM provider. Among those who sought services of a professional CAM provider, 33 percent saw one type of CAM provider, 11 percent saw two types of CAM providers, and 8 percent saw three or more different types of CAM providers.

These findings have implications for the design of future clinical trials to assess the safety, efficacy, and cost-effectiveness of CAM therapy use by the adult population. Although it is still important to evaluate individual therapies for individual conditions, a research portfolio that is limited to this approach may not adequately simulate CAM therapy use by the adult population. It may therefore be important methodologically to design some studies that offer patients access to multiple CAM therapies across multiple CAM professional groups, as this would be closer to real-life experience.

It is also interesting to reflect on the sequence, in which adults use CAM therapies in the context of their overall health care management. Eisenberg et al. (1993, 1998) documented that the overwhelming majority of CAM users also sought conventional medical care for their principal medical conditions. In a separate analysis, Eisenberg et al. (2001) explored the sequence in which individuals seek CAM therapy and found that 70 percent of respondents typically sought the services of a CAM professional concurrently with or after their visit to a medical doctor. Less than 15 percent reported that they had seen a CAM therapy provider before an evaluation of their medical concern by a medical doctor. As such, future research may need to incorporate options for concurrent and concomitant conventional and CAM therapies for individuals to see whether one is better than the other or, alternatively, whether the two together (as usually occurs in common practice) provide perceived or real improvements in clinical outcomes or cost-effectiveness, or both.

Knowledge of the basis for decision making by the U.S. public regarding when and how they access complementary therapies either through professional contact with licensed practitioners or some form of self-care is lacking. This represents a relatively unchartered line of inquiry that also has implications for future studies in this field.

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 problems 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 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 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 interferes 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.

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Footnotes

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.

2

CAM use included megavitamin therapy and prayer.

3

“Quality-adjusted life years integrate mortality and morbidity to express health status in terms of equivalents of well-years of life” (Kaplan, 1988).

Copyright © 2005, National Academy of Sciences.
Bookshelf ID: NBK83794

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