An overview of some of the integrative therapies used in palliative and end-of-life care. Original presentation at AAHPM annual assembly.

1. Complementary &
Integrative Medicine:
What You Need to Know for
the Boards and for Practice
Delila Katz, PharmD • Suzana Makowski, MD MMM
University of Massachusetts Medical School, UMass Medical Center
Worcester, MA

2. We have no financial disclosures

3. Objectives
 Review general concepts, utilization
trends
 Address clinical challenges in palliative
care regarding CAM
 Apply evidence to palliative care cases

4. What is CAM ?
A group of diverse medical and health care
systems, practices, and products that are not
presently considered to be part of conventional
medicine.
 Complementary medicine is used together with
conventional medicine.
 Alternative medicine is used in place of conventional
medicine.
 "Integrative medicine" combines treatments from
conventional medicine and CAM for which there is some
high-quality evidence of safety and effectiveness.
http://nccam.nih.gov/health/whatiscam/

5. Prevalence & Use Patterns
Many Americans use complementary and
alternative medicine (CAM) in pursuit of
health and well-being.
 The 2007 National Health Interview Survey (NHIS)
 ~ 38 percent of adults use CAM
 CAM use was more prevalent among people with a
prior diagnosis of cancer
 40-80% of cancer survivors reported using CAM
 18 % had used multiple CAM therapies
 Herbal and other natural products 20%
 Deep breathing (14 percent), and meditation (9 percent).
http://nccam.nih.gov/health/whatiscam/

6. Use of complementary/alternative
therapies by women with
advanced-stage breast cancer
 Background
 Pattern of complementary/alternative medicine (CAM) use among a
group of patients with advanced breast cancer
 Results
 73% CAM; relaxation/meditative techniques and herbal medicine
were the most common.
 Most commonly cited primary reason for CAM use was to boost the immune
system
 Second most common, to treat cancer.
 Friends or family members and mass media were common primary
information source's about CAM.
 Conclusions
 A high proportion of advanced-stage breast cancer patients used
CAM. Discussion with doctors was high for ingested products. Mass
media was a prominent source of patient information. Credible
sources of CAM information for patients and physicians are needed.
BMC Complementary and Alternative Medicine 2002, 2:8

7. Out of pocket costs of CAM in
the US

8. Must it be ?
 Many patients who use
CAM still don’t tell their
physicians.
 What is the responsibility
of the palliative
medicine clinician?

9. Patients Clinicians
Need to perceive openness Need to demonstrate openness
Need to perceive respect Need to demonstrate respect
Need to perceive interest Need to demonstrate interest
Use driven by cultural identity Need to initiate discussion
Use driven by family history
Can ask about TM/CAM in acute
setting
Use driven by proximity to home
Can still be clinical and evidence-
based
Do not have outward
characteristics
Need not be content experts
’They Don’t Ask Me So I Don’t Tell Them’
Shelley BM et al. Ann Fam Med 2009 7: 139-147; doi:10.1370/afm.947

10. Responding to “positive
thinking”
You 43 year old patient with advanced
hepatocellular carcinoma recently returned
from South America where she was getting
care at an alternative medicine center. She
shares that her alternative care practitioner
tells her to focus on the positive and not think
about death, as this will allow it to become
part of the possible.
Code status needs to be addressed – how to
respond?

11. Types of CAM ?
Mind-body medicine
Natural products
Manipulative and body-based practices
Movement therapies
Energy medicines
Whole systems
 Chinese, ayurvedic, anthroposophical, homeopathy,
naturopathy
http://nccam.nih.gov/health/whatiscam/#types

12. Mind-Body Medicine

13. Question
 Ms Johes is a 63 yo with
ovarian cancer, who has
recently experienced
increased difficulty with
insomnia. Her current
medications include:
morphine SR 45mg bid,
morphine IR 15mg q2 hours
prn, dexamethasone 4mg
qam, and a good bowel
regimen. She shares that her
mind is busy with worry, and
once she falls asleep, she
stays asleep. The chaplain
has been working with her.
Which of the following
should you recommend
next?
a) Lorazepam before bed
b) Chamomile before bed
c) Sleep hygiene
d) Lavender footbath
before bed
e) Kava kava before bed
f) Metatonin before bed

14. Question
 Ms Johes is a 63 yo with
ovarian cancer, who has
recently experienced
increased difficulty with
insomnia. Her current
medications include:
morphine SR 45mg bid,
morphine IR 15mg q2 hours
prn, dexamethasone 4mg
qam, and a good bowel
regimen. She shares that her
mind is busy with worry, and
once she falls asleep, she
stays asleep. The chaplain
has been working with her.
Which of the following
should you recommend
next?
a) Lorazepam before bed
b) Chamomile before bed
c) Sleep hygiene
d) Lavender footbath
before bed
e) Kava kava before bed
f) Metatonin before bed

15. Insomnia and interventions
 Lorazepam (and other benzos) – may have a “hangover”
effect. Not first line. Behavorial approaches are
 Chamonile is a mild hypnotic tea. Research is poor, limited. But
it is generally safe and may be added as part of “sleep hygeine”
 Lavendar foot bath – is essentially a means of sleep hygiene,
with an added “twist”. Behavioral interventions – including sleep
hygiene, CBT, are first line treatment with strongest evidence of
support. Lavender aromatherapy has been shown to decrease
delirium in the elderly.
 Kava Kava and Valerian are two of the strongest hypnotics of
the herbal-kind. Kava has been banned in EU due to risk of liver
failure. Valerian has the strongest evidence as herbal treatment
for insomnia.
 Melatonin is a hormone that normalizes the sleep-wake cycle. It
won’t help her “busy-mind,” but may be helpful if she had a
sleep-wake cycle shift, or if on SSRI. (2- 7 mg)

16. Burnout
Dr. E. Is mid-way through
his hospice & palliative
care fellowship. He
confides that he has is
more distant and
detached with patients.
You have also noticed
this.
He is exhausted and also
shares that he is having
difficulty sleeping. He
wonders whether he has
made the right career
decision.
What would you recommend
to him?
a) Recommend St. John’s Wort
(hypericum perforatum)
b) Recommend an SSRI
c) Recommend bright light
therapy
d) Recommend mindfulness
meditation

17. Burnout
Dr. E. Is mid-way through
his hospice & palliative
care fellowship. He
confides that he has is
more distant and
detached with patients.
You have also noticed
this.
He is exhausted and also
shares that he is having
difficulty sleeping. He
wonders whether he has
made the right career
decision.
What would you recommend
to him?
a) Recommend St. John’s Wort
(hypericum perforatum)
b) Recommend an SSRI
c) Recommend bright light
therapy
d) Recommend mindfulness
meditation

19. Natural products

20. Question
You are working at your local hospital on the Consultation
Service and meet a 47 year old man with metastatic
colorectal cancer. His oncologists asks you see him in the
clinic to help with goals of care, explaining, “He insists on using
alternative therapies. I can’t go through these bags of herbs
and want him to stop all. Maybe you can help.”
After clarifying with the patient that he would like to try some
first line therapies, he also is interested in maintaining his
“herbal” approaches, that help give him a sense of control.
He is willing to stop some, but not all.
Which are safe and has the strongest evidence to provide
him some chemoprotective benefits and symptom relief?
a) Vitamin E
b) Tumeric (Curcuma longa)
c) Ginger (Zingiber officinale)
d) St. John’s Wort (Hypericum
perforatum)

21. Question
You are working at your local hospital on the Consultation
Service and meet a 47 year old man with metastatic
colorectal cancer. His oncologists asks you see him in the
clinic to help with goals of care, explaining, “He insists on using
alternative therapies. I can’t go through these bags of herbs
and want him to stop all. Maybe you can help.”
After clarifying with the patient that he would like to try some
first line therapies, he also is interested in maintaining his
“herbal” approaches, that help give him a sense of control.
He is willing to stop some, but not all.
Which are safe and has the strongest evidence to provide
him some chemoprotective benefits and symptom relief?
a) Vitamin E
b) Tumeric (Curcuma longa)
c) Ginger (Zingiber officinale)
d) St. John’s Wort (Hypericum
perforatum)

22. Link, A., Balaguer, F., & Goel, A.
(2010). Biochemical
pharmacology, 80(12), 1771-92.

23. Ginger

24. Curcumin

25. Curcumin
 1666 articles on curcumin in Pubmed (1/2012)
 Doses: 1-4 g PO in divided doses daily.
 MOA:
 Curcuminoids induce glutathione S-transferase and are potent inhibitors
of cytochrome P450.
 Turmeric acts as a free radical scavenger and antioxidant, inhibiting
lipid peroxidation and oxidative DNA damage. It also inhibits activation
of NF-kB 17, 20, c-jun/AP-1 function, and activation of the c-Jun NH2-
terminal kinase (JNK) pathway.
 May decrease efficacy of cyclophosphamide-based
chemotherapies
 Used for: anti-tumor treatment, arthritic pain, IBD
 Contraindicated in bile-duct obstruction

26. St. John’s Wort –
Hypericum perforatum
Clinical Pearls: St. John’s Wort is contraindicated for patients on HIV
protease inhibitors and non-nucleoside reverse transcriptase inhibitors.
Also caution with SSRIs – SSRI + SJW consider serotonin syndrome

27. Question
 A nurse calls you from a
patient’s home. The patient
has a hospice diagnosis of end-
stage heart failure. She has
been on metoprolol, enalapril,
furosemide, morphine prn. Pt
complains of new headaches,
increased thirst, edema despite
increase in furosemide, fatigue
and leg swelling
 Other PMH includes: mild
asthma, GERD
 On exam: BP 170/106, P98
irregular. Edema is significant
bilaterally
An infusion (herbal
tea) with which of
the following is the
most likely cause?
a) Ginger
b) Licorice
c) Dandelion
d) Peppermint

28. Question
 A nurse calls you from a
patient’s home. The patient
has a hospice diagnosis of end-
stage heart failure. She has
been on metoprolol, enalapril,
furosemide, morphine prn. Pt
complains of new headaches,
increased thirst, edema despite
increase in furosemide, fatigue
and leg swelling
 Other PMH includes: mild
asthma, GERD
 On exam: BP 170/106, P98
irregular. Edema is significant
bilaterally
An infusion (herbal
tea) with which of
the following is the
most likely cause?
a) Ginger
b) Licorice
c) Dandelion
d) Peppermint

29. Licorice

30. Licorice with glycyrrhizin
 Licorice – pseudoaldersteronism (HTN, metab alkalosis,
hypokalemia)
 People with the following conditions should not take licorice:
 Heart failure
 Heart disease
 Fluid retention
 High blood pressure (hypertension)
 Diabetes
 Kidney disease
 Liver disease
 Pregnant or breastfeeding women should not take licorice.
 Use of any licorice product is not recommended for longer
than 4 - 6 weeks.
What is the alternative? - Deglycyrrhized licorice (DGL)

31. Marijuana as a natural
product
 48 yo woman who has stage IV colon
cancer and has increasing nausea, has
been smoking 3-4 marijuana
cigarettes/day to help. Patient also has
had recent radiation to the pelvis
 What are your concerns?

32. Marijuana – commercially
available alternatives
Dronabinol
Nabilone
CME (available in Canada)
Medical marijuana
Not medical marijuana

33. Manipulative & Body-based
practices

34. Massage therapy
 A nurse at your hospice has recently
obtained a 2000 hour certification in
massage therapy and would like to bring
massage as a therapy to patients at
home. The administrator says to you,
“Anyone would want a massage, but
before I invest, what’s your perspective
as our medical director. The study by
Kutner et al – showed some benefit, but
questioned its efficacy because of a
limited duration. What do you think?”
 What is your response?

35. Acupuncture
 Which of the following is reasonable to
use acupuncture for?
 Pain
 Nausea/vomiting
 Xerostomia
 Headaches

36. Movement
Therapies

37. Energy Medicine

38. Whole Medical Systems

39. Anthroposophical Medicine

40. Benign or Malignant
62 yo male with end stage pancreatic
cancer has been using alternative
medicine for 20 years, he has strongly
held belief that the toxic environment
is worsening his illness. To detoxify he
uses
 Cholonics
 Chelation
 Herbal teas and fasting
What do you need to be concerned
about ?

41. Question
 You receive a call from Dr. Reyes, a local naturopathic physician
to refer one of her patients to your hospice. She has been the
primary care physician for Mr. Jones, an 81 year old gentleman
who has metastatic pancreatic cancer with liver involvement.
He does not wish chemotherapy, and hopes to focus on quality
of life. He has no other physician.
 Current medications: Morphine CR 80mg bid, morphine IR 15-
30mg QID prn, dexamethasone 4mg daily, deglycyrrhized
licorice, peppermint extract, curcumin, valerian prn anxiety or
insomnia.
What role can Dr. Reyes play when Mr. Jones is on your hospice?
What are your concerns?

42. Summary
 There are similar challenges in integrative medicine as there are
in conventional medicine with regards to our field.
 Communication is important – to avoid dangers, to enhance
clinician-patient rapport.
 Recognize that our field is perhaps the most integrated of all

43. Resources
 http://www.mskcc.org/mskcc/html/11570.cfm
 http://nccam.nih.gov/ (National Center For Complementary and Alternative
Medicine)
 http://ods.od.nih.gov/ (Office of Dietary Supplements)
 http://naturaldatabase.therapeuticresearch.com/home (Natural Medicines
Comprehensive Database)
 http://www.integrativeonc.org/ (Society for Integrative Oncology)
 http://fitsweb.uchc.edu/student/selectives/atolsdorf/index.html
 http://www.drweil.com/