A clinical tool for evaluating complementary and alternative medicine utilization and risk

Complementary and alternative medicine (CAM) is widely used in Canada and throughout the world, making it inevitable that family physicians will encounter CAM use in their patients. CAM therapies are highly variable and are not subject to regulation or oversight, making some such modalities potentially dangerous. Presently, CAM use is discussed during standard history taking, but the information gathered may be of limited utility due to the wide variety of CAM that exists; such diversity makes it practically impossible for one physician to know the risks associated with each CAM. Additionally, some CAM may not identified as such by the patient (eg chiropractic) and may not be reported during a standard patient interview. There currently exists no standardized method of collecting a patient’s history of CAM use, or for assessing risk based on the information collected. Here, we present a clinical tool that helps to screen for use of CAM and stratify patients into risk categories accordingly. It also makes suggestions for management and follow-up of these patients according to their risk category. Included are several quick reference tables to enable physicians to rapidly stratify patients into an appropriate category. This test may help to screen patients for CAM use that puts their health at risk, thereby increasing detection, and enabling timely intervention by the physician to prevent adverse events due to CAM use.


background
Complementary and alternative medicine (CAM) is defined by the Canadian Medical Association and United States National Institutes of Health as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine."3][4] Despite the high prevalence of CAM use in the Canadian population and its ability to affect the health and safety of a patient, it can go unaddressed or undisclosed in the family physician's clinic. 5AM can be most usefully divided into three categories: products, interventions, and practitioners.Products include items typically bought by consumers, such as herbal teas and remedies, vitamins and minerals, homeopathic remedies, traditional Chinese medicines (TCM), and many others.Interventions refer to practices such as spinal manipulation, electromagnetic field therapy, crys-tal healing, and others which may or may not involve a practitioner.Practitioners are individuals who market themselves as care providers in particular fields, such as chiropractic, TCM, homeopathy, naturopathy, Ayurveda, acupuncture, and others.Practitioners may or may not prescribe or provide both products and interventions. 1

cause for concern
7][8] Due to poor regulation and the lack of medical education of most practitioners, CAM can pose significant threats to the health of Canadians through a variety of mechanisms: • The traditional Chinese herb ma huang contains unregulated levels of ephedrine and can cause numerous adverse effects including palpitations, hypertension, arrhythmia, nervousness, tremors, seizures, heart attack, stroke, and death. 9• Ginseng is a naturopathic remedy marketed under the name COLD-FX as an immune system booster that will prevent viral influenza and strengthen normal body function, among other such claims.Serious drug interactions with warfarin have been described, as well as stimulation of manic episodes in psychiatric patients on antidepressants. 10• Ayurvedic medicine is a form of traditional Indian medicine that stresses the use of plant-based therapies, yet Ayurvedic medicines have been shown to contain toxic levels of heavy metals; one study found that one in five Ayurvedic herbal medicine products contained potentially harmful levels of lead, mercury, or arsenic. 11• Chiropractic is an intervention which focuses on spinal manipulation therapy, often marketed as a panacea, but numerous serious adverse effects have been reported as a result of chiropractic manipulation, including stroke, neuropraxic injury, epidural hematoma, paraplegia, and fatal posterior circulation cerebrovascular accident. 12-15• Acupuncture is a component of some TCM and involves puncturing a patient's skin with needles along so-called meridian lines to achieve therapeutic effect.[18][19][20]

A clinical tool for evaluating complementary and alternative medicine utilization and risk
Keegan Guidolin (Meds 2017), Mackenzie Drew (BSc Cand) Faculty Reviewer: Dr Michael Craig, MD, CCFP (Department of Family Medicine) This represents a brief illustration of the dangers posed by CAM therapies.Of course, all medical therapies carry some risk; however, in the cases of most CAM, no benefit has been shown via randomized controlled trial, making the risk-benefit calculation one-sided. 21ot all CAM poses a direct threat to health.CAM is a catch-all term which should be parsed for clarity: complementary medicine is unconventional therapy used concurrently with conventional therapy, while alternative therapy is unconventional therapy used exclusively, in place of conventional therapy.This is an important distinction because an individual using alternative medicine is, by definition, foregoing conventional treatment -this poses an entirely different threat. 22CAM such as homeopathy, crystal healing, and reiki poses no direct threat, but may prevent people from seeking appropriate medical attention.

the cam risk assessment tool
Numerous studies involving CAM have highlighted the need for a better method of assessing, following, and managing CAM-using patients. 21Here we present a clinical tool intended for use by the family physician, or any physician following a patient for an extended period of time.This tool represents a means of assessing patients' use of CAM and risk of associated harm, and classifies patients into categories with targeted indications for follow-up.This tool is designed to be used when taking the initial patient history for a new patient in a family practice, but may be implemented at any time.
The tool itself consists of three components: (1) a set of initial questions to determine whether or not the patient uses CAM (CAM determination), (2) a set of questions to determine the qualitative potential for harm as a result of CAM use, and (3) a set of questions to determine whether the patient uses CAM exclusively (alternatively) or alongside conventional medicine (complementarily).These question sets help to quickly and easily stratify patients into risk categories (Figure).Each question set is aimed at evaluating the use of CAM from each of the three categories (products, interventions, and practitioners).These questions are meant only to screen for CAM which the patient may not consider outside of conventional medical care.For example, patients may consider chiropractic manipulation con- ventional medical treatment when a physician asks.The questions are not meant to be exhaustive and follow-up questions are necessary for an adequate assessment of CAM use.
Included is a patient scoring system and score-dependent management recommendations (Table 1).These should be taken only as a list of options to consider based on the relative risk.They are not meant to be exhaustive, nor are they meant to be applied to every patient-naturally, the physician must apply the entirety of this tool on a case-by-case basis.To help simplify the application of the tool, two Quick Reference Charts are included.The first is a list of types of CAM practitioners; patients who identify any of these practitioners as someone they regularly see for health advice can be considered to use CAM (Table 2).The second is a list of CAM modalities stratified into likely harmless and potentially harmful categories based on literature review (Table 3).The use of this table helps to determine a patient's risk of harm (CAM class I vs II).
The ultimate goal of the management considerations presented by this tool is the reduction and eventual elimination of CAM use by the patient.This is theoretically achieved over multiple visits, with CAM score reassessment at each; however, particular care should be taken in a few situations.Firstly, in cases of CAM class B, or use of alternative medicine, care must be taken to avoid confrontation.Since these patients use CAM as an alternative, their trust in mainstream medicine may be tenuous, and thus, if a physician addresses CAM use too aggressively, patient trust may be lost and the patient may be lost to follow-up.Secondly, special attention should be given if a child is being treated with CAM, particularly CAM class II (po-class management considerations CAM 0 (No CAM) • Repeat screen at periodic health assessment (PHA).

CAM IA • Complementary
• Likely harmless • Education regarding lack of evidence for CAM.
• Encourage physician consultation before starting new therapies.
• Contact CAM practitioner, open communications regarding treatment prescribed.
• Works towards dispelling CAM use, move patient towards CAM class 0.

CAM IB • Alternative • Likely harmless
• Non-aggressive discussion recommended -trust in mainstream medicine and physicians may be tenuous.tentially harmful CAM).Continued use of potentially harmful CAM on pediatric patients in the face of physician advice to the contrary raises serious concerns regarding abuse, and the involvement of the Children's Aid Society and analogous groups may be indicated.Ultimately, follow-up is key in both of these scenarios, as the patient-physician relationship should be developed and leveraged appropriately to ensure the health of patients who use CAM.

limitations and future directions
The relative lack of existing research on the consideration of CAM as a risk factor for future medical conditions makes a tool like the one presented here inherently qualitative in nature.It is difficult to make empirical risk evaluations or evaluate the effect of the management considerations listed here in a quantitative fashion.As such, this tool is presented as a means of standardizing the CAM component of a patient history in order to act as a screen.Primarily, this tool aims to help physicians take a more complete history with regard to CAM use in their patients.Future studies may assess whether the use of this tool increases detection of CAM use in patients at the level of the primary caregiver.

Figure :
Figure: CAM risk assessment tool.

Table 1 :
• Gain patient trust.• Work towards a CAM class IA designation before addressing lack of evidence for CAM.• Contact CAM practitioner, open communications regarding treatment prescribed.• Address immediate health concerns at physician's discretion.• Follow patient closely.Advise against use of harmful CAM only if patient is open to the idea.• Pediatric: Refer to Children's Aid Society (or analogue) at physician's discretion.Summary and Indications: Class Definitions and Corresponding Management Considerations

Table 2 :
Practitioner Quick Reference: List of CAM Practitioners a a S23f-identified as CAM practitioners in survey and promotional publications.22,23

Table 3 :
Harm Quick Reference: Likely Harm Associated with Complementary Use of Common CAM a Harmlessness is not an endorsement of CAM effectiveness.b Harm classification based on complementation of conventional care; alternative care has inherent risks.c Unregulated or poorly regulated.