Terminology and definitions

It wasn’t that long ago that “quackery” denoted what is today termed CAM. Other terms included dubious, unconventional, unproven, questionable, nonstandard, and irregular therapies. Complementary and alternative have been generally used, but not always rigorously or appropriately. Many today prefer to call this treatment integrative medicine, to reflect the inclusion of evidence-based therapies, regardless of their origin, in conventional practice. There is even taxonomy for CAM. The authors have favored the terms mainstream and nonmainstream therapies because there have certainly been routine practices that were not supported by evidence or proven safe (ie, tonsillectomy and adenoidectomy, certain arthroscopic and back operations, and even the recent popularity and use of nonsteroidal antiinflammatory drugs [NSAIDs]) and others that are evidence-based but eschewed by given cultures (ie, balneotherapy). However, for purposes of this discussion the authors largely use the term CAM.

Who uses CAM and why?

Most patients, particularly those with chronic diseases, use CAM. Indeed, the popularity of CAM therapies has led to their incorporation into the medical curriculum at many schools and hospitals and to serious efforts to study them scientifically (and the authors have elsewhere praised certain of those individuals ), to the establishment of a CAM center at the National Institutes of Health (despite opposition from the scientific community), and an increasing aura of legitimacy.

CAM therapies are widely used throughout the world across geographic, ethnic, social, and economic boundaries. Table 1 illustrates this generally and for the patients with rheumatic disease specifically.

Box 1 summarizes the prevalence of use and the cost of CAM in the United States. CAM users tend to be women, well educated, and economically comfortable.

CAM therapies are used for chronic as opposed to life-threatening medical conditions, including cancer, AIDS, gastrointestinal problems, chronic renal failure, depression, and eating disorders. In particular, CAM therapies are frequently used by patients with rheumatologic conditions, such as arthritis, chronic back pain, and other painful musculoskeletal disorders. There are now more patient visits to CAM practitioners than to primary care physicians in the United States. As has long been documented to be the case, most CAM users do not inform their medical doctors of their use of alternative therapies. Almost 50% of users do so without any professional supervision. Patients are likely to choose nonpractitioner-based CAM therapy over practitioner-based CAM therapy.

The use of CAM increases with the number of patients’ medical conditions and the number of physician visits. Patients who reported poor health had substantially higher rates of use of CAM therapies than those who perceived themselves to be in better health (52% vs 33%). Studies of patients with specific rheumatologic conditions, such as fibromyalgia, osteoarthritis, and systemic lupus erythematosus, demonstrated that most CAM users were generally people with chronic disease, poorer functional status, and higher levels of pain.

Patients use CAM therapies because these therapies (1) are consonant with their lifestyle and/or belief system, (2) produce a sense of a holistic approach to medical care, (3) are perceived to be safer and more natural than prescription drugs, (4) help them to achieve greater control over their illness and its management and reflecttheir rejection of or dissatisfaction with conventional medical care (for many reasons including perceived impersonal skills of practitioners, cost and toxicities of mainstream therapies, and uncertainties about outcomes). Practitioners of CAM are often considered more available, more empathetic, more caring, as investing more time with patients, and as conveying more confidence and optimism about outcomes than regular physicians. Studies have shown that patients preferring CAM tended to be more psychologically distressed and considered their health poorer than that of others. Most patients use CAM to complement conventional care rather than to substitute for it.

Who uses CAM and why?

Most patients, particularly those with chronic diseases, use CAM. Indeed, the popularity of CAM therapies has led to their incorporation into the medical curriculum at many schools and hospitals and to serious efforts to study them scientifically (and the authors have elsewhere praised certain of those individuals ), to the establishment of a CAM center at the National Institutes of Health (despite opposition from the scientific community), and an increasing aura of legitimacy.

CAM therapies are widely used throughout the world across geographic, ethnic, social, and economic boundaries. Table 1 illustrates this generally and for the patients with rheumatic disease specifically.

Box 1 summarizes the prevalence of use and the cost of CAM in the United States. CAM users tend to be women, well educated, and economically comfortable.

CAM therapies are used for chronic as opposed to life-threatening medical conditions, including cancer, AIDS, gastrointestinal problems, chronic renal failure, depression, and eating disorders. In particular, CAM therapies are frequently used by patients with rheumatologic conditions, such as arthritis, chronic back pain, and other painful musculoskeletal disorders. There are now more patient visits to CAM practitioners than to primary care physicians in the United States. As has long been documented to be the case, most CAM users do not inform their medical doctors of their use of alternative therapies. Almost 50% of users do so without any professional supervision. Patients are likely to choose nonpractitioner-based CAM therapy over practitioner-based CAM therapy.

The use of CAM increases with the number of patients’ medical conditions and the number of physician visits. Patients who reported poor health had substantially higher rates of use of CAM therapies than those who perceived themselves to be in better health (52% vs 33%). Studies of patients with specific rheumatologic conditions, such as fibromyalgia, osteoarthritis, and systemic lupus erythematosus, demonstrated that most CAM users were generally people with chronic disease, poorer functional status, and higher levels of pain.

Patients use CAM therapies because these therapies (1) are consonant with their lifestyle and/or belief system, (2) produce a sense of a holistic approach to medical care, (3) are perceived to be safer and more natural than prescription drugs, (4) help them to achieve greater control over their illness and its management and reflecttheir rejection of or dissatisfaction with conventional medical care (for many reasons including perceived impersonal skills of practitioners, cost and toxicities of mainstream therapies, and uncertainties about outcomes). Practitioners of CAM are often considered more available, more empathetic, more caring, as investing more time with patients, and as conveying more confidence and optimism about outcomes than regular physicians. Studies have shown that patients preferring CAM tended to be more psychologically distressed and considered their health poorer than that of others. Most patients use CAM to complement conventional care rather than to substitute for it.