Kingdom of Saudi Arabia

Ministry of Education
Imam Muhammad Ibn Saud
Islamic University
College of Medicine

Integrating CAM practices into the conventional health

systems (integrative medicine)

Supervised by : Dr.Saud Alsanad

Written by:

Joud Nasser Bindekhayel 440023342

Raghad Yousef AlNader 440023333
Raghad Saleh AlNajdi 440023291
Reem Ayed Bin Twalah 440022992
Lama Abdullah Alqasayer 440019363
Nouf Mohammed Aldhfayan 440019598
Raghad Abdullah Melhi 440021735
Layan Ahmed Alrehaili 440022434
1.0 Abstract
Integrative medicine (IM) brings complementary and conventional medicine into a harmonized
healthcare system, and it has an important role in healthcare systems where it solves a lot of issues
facing medicine. IM has gotten a lot of attention in recent times, and there are still many aspects of it
to be figured out. In this paper research and websites that were mainly concerned with IM were
reviewed to cover the objectives. Results show IM to be widespread around the world, with many
practitioners being trained to give safe and evidence-based integrative treatments. However,
Despite the recent advances IM have had, it still faces challenges like the flawed clinical trials, the
non-understood mechanisms of some herbs, the undefined doses and routes of administration. Many
have tried to describe the best module to integrate CAM into conventional medicine, such
modules are the “ideal” module proposed by Lewith and Bensoussan, ‘selective combination’ and
many other modules. IM comes in handy when people have doubts about conventional medicine, and
when patients want to feel in control of their illness. Efforts have been made by organizations to
determine the safety of CAM practices and decides which of them to be integrated into conventional
healthcare systems, and organize them.

2.0 Introduction
The modern medicine healthcare system or conventional medicine is expanded to be available for
almost all people around the world, but this surely doesn't erase the role of Complementary and
Alternative medicine (CAM) in society especially when conventional medicine fails to solve some
issues. CAM are treatments that fall outside of mainstream healthcare (1), and it has an important
value to people culturally and religiously, and people tend to use it for several reasons such as the
fact that it offers “natural” treatment, focuses on the patient instead of the disease, and being holistic,
among other reasons that serve each patient individually (2). For that, a safe and effective approach
to medical care that combines conventional medicine with CAM practices has been introduced to
healthcare systems called Integrative medicine (IM) (3).
IM as the National Library of Medicine defines it is “practicing medicine in a way that selectively
incorporates elements of complementary and alternative medicine into comprehensive treatment
plans alongside solidly orthodox methods of diagnosis and treatment” (4). IM solved the concerns
that were raised by doctors about CAM in three main ways. To begin with, the questionable quality
of CAM is now organized and supervised by governmental institutes to guarantee the best quality of
healthcare provided to patients. In addition, healthcare organizations now highlight CAM
medications and procedures to put it under tests and encourage researchers to provide evidence of
their efficiency (5). Lastly, doctors now are more aware of CAM and have enough knowledge to
discuss CAM usage by their patients, reducing the gap that was between them (6).

Knowing the importance of IM, this paper is going to view it from several aspects. The target is to
discuss the rationale behind IM, understand what kind of challenges IM practices face, mention some
IM modules that are currently available, know the prevalence of IM, and finally assess the safety and
regulation that may be needed for IM.

3.0 Methods
The articles related to Integrative medicine were appraised from scientific databases like PubMed
and Google scholar. The keywords used are “Integrative medicine” “CAM practices” “CAM in
conventional medicine”.
Searches were filtered to include systematic reviews, RCT, and meta-analysis studies, and to find
more uncommon information the search included some case reports.
Further searches were done according to objective including specific keywords to each one.

4.0 Results and discussion

4.1 The rationale behind integrative medicine

The term of Alternative Medicine (IM) has been known for years. However, the term is evolving
every year with new discoveries and proves. These new methods can be used in a complementary
medicine with conventional medicine, combined with one another to improve the patients' health and
wellness (7). A health care practitioner who knows the patient beliefs and spiritual needs is able to
help the patients psychologically. Which play an important role in the patient journey with the disease
(8). People seek out these alternatives because first, they may have some doubts about the
conventional treatment; second, the patients feel in control of their illness because they believe that
alternative treatments is stronger and more effective than the conventional medicine. (9)
Today's health-care consumers, practitioners, researchers, and policymakers, the broad use of
complementary and alternative medicine (CAM) is critical. The overall number of visits to
complementary and alternative medicine practitioners exceeds the total number of visits to all primary
care physicians. Hospitals, managed care organizations, and traditional practitioners are all adopting
complementary and alternative medicine (CAM) therapies into their practices. Although the boundary
between traditional medicine and complementary and alternative medicine (CAM) is not often clear,
there is a conceptual difference. Conventional medicine has a tendency to base its practices on the
most up-to-date scientific evidence. CAM, on the other hand, prefers to base its methods on evidence-
informed practices—evidence that may or may not fulfill the most stringent efficacy criteria. When
possible, IMH tries to mix complementary and alternative medicine with traditional care. Some
complementary and alternative therapies are now available in hospitals and are occasionally paid by
insurance companies (10). Acupuncture and various forms of manual manipulation (such as
chiropractic or osteopathic manipulation) are examples. Because CAM treatments like acupuncture,
botanical medicine, manual manipulation treatments, and homeopathy are becoming more popular,
medical school curricula are increasingly including information on them. Some complementary and
alternative therapies haven't been put to the test in well-designed studies. A lack of data from well-
designed research, on the other hand, is not confirmation that a treatment is unsuccessful. Many
complementary and alternative therapies are reported to have been used for hundreds or thousands of
years. Acupuncture, meditation, yoga, therapeutic diets, massage, and herbal medicine are some of
them. A long history of use can be used to support the efficacy of complementary and alternative
therapies. When it comes to the risk of CAM therapies, some are definitely safe, even safer than
traditional medicine. (11)

4.2 Challenges that face Integrative medicine

Integrative medicine has proved to be commonly used among many patients ,especially ,patients
with chronic diseases .Also ,integrative medicine faces many challenges despite the recent advances
that have been seen .Firstly ,many clinical trials of complementary and integrative medicine have
significant flaws .For example ,insufficient statistical power ,poor controls ,inconsistency of
treatment or products and lack of comparisons with other different treatments ,also with placebo or
even with both.(13) For the purpose of overcoming these challenges with integrative medicine ,
larger ,well designed studies are necessary before making authoritative recommendations .Secondly ,
optimal dosing ,route of administration and schedule of dietary supplements need to be determined
systematically to make an authoritative recommendation .Furthermore ,the frequency and extent of
the drug reactions and interactions remain undiscovered.(13) Thirdly ,there are many herbal
supplements with unknown mechanisms.(12) So ,in order to improve the safety of integrative
medicine ,exploration and eventual discovery of plausible scientific mechanisms ,theoretical and
historical investigations are essential in order to further and fully understand the holistic role and
claims of complementary ,alternative and integrative medicine within the context of western
medicine .Fourth ,many practitioners of integrative medicine focus on the symptom of the disease
rather than the primary pathology .There are many diseases that share similar symptoms but have a
completely different pathological background .Treating two similar symptoms without concerning
the pathology of the symptoms could result in increasing the risk for worsening the disease.(13)

4.3 Integrative medicine modules

The debate commenced integrating complementary medicine (CAM) and conventional medicine
at the beginning of this decade. However, the emergence of integrative medicine (IM) and
modification of health care models has primarily resulted from a revolution led by consumers looking
for a new kind of medicine that incorporates both types of care. The ‘‘ideal’’ model described by
Lewith and Bensoussan was the selective incorporation of the most effective CAM and conventional
medicine (‘integration’) for the optimal health outcome for the client. The Birkenholm Centre in
Denmark was established as such a model. Another instance of this model is the Marylebone Health
Centre in London, in which condition-based guidelines (as opposed to individualized care plans) are
used for CAM service delivery. In Australia, the Shellharbour Hospital operates a single-site medical
complex offering both CAM and biomedical services. In addition, it sells natural and conventional
medical products in a facility adjacent to the hospital. One model of IM clinical practice implemented
by the Department of Family Medicine at the University of Michigan that used the ‘selective
combination’ model was evaluated. An integrative, patient-centered clinical practice is described with
a focus on patient well-being. Elements of CAM and conventional medicine were selected for healing
plans to be individually shaped. And from a selection of activates and practices for spirit, emotion,
mind, body. Patients participate in their healing engaged through it. Outcomes for this practice were
evaluated, and the patient satisfying. Results suggest that the selective IM approach contributed to
high levels of patient satisfaction and improved perceptions of physical health, resulting in increased
patient satisfaction. This proposed model represented by Maizes, Lewith and Bensoussan described
this most effective model. However, they also argued that it may not always be an achievable ideal
given the epistemological differences and ontological conflict between the two systems of medicine.
(14)

4.4 Prevalence of IM practices systems

The utilization of IM is widely practiced in many countries worldwide. Integrative medicine
carries along with a focus on safety and evidence. Many integrative medicine physicians have
received professional training in safe, evidence-based integrative treatments. An integrated
medicine physician will collaborate with the healthcare professionals to provide patients with the
best overall treatment and support available
Moreover, there is a study that demonstrates the CAM use over a 12-month period as reported
from the 49 surveys conducted in 15 countries. It shows the percentage of the general population
using at least one type of CAM (all-CAM use). Currently, CAM appears to have a significant role
for patients with common painful long-term conditions in providing choices to enable individual
needs to be met (15)

Integrative medicine practitioners offer modalities and therapies that have been well researched
for safety and efficacy.
There are some instances of integrated medicine (16):
1-Acupuncture.
-Up to 1.5% of the US population has utilized acupuncture at some point. (17)

-The utilization of acupuncture became increasingly popular in Taiwan from 2002 to 2011. The
one-year prevalence of acupuncture use among adults increased from 7.98% in 2002 to 10.9% in
2011. (18)

2-Homeopathic Medicine.
-Rates in the USA, UK, Australia and Canada all ranged from 0.2% to 2.9% (19)
- Around 10% of India's population—more than 100 million people—depend solely on
homoeopathy for their health care, according to the Indian government. (20)

3-Aromatherapy.
- The global aromatherapy market size was estimated at USD 1.6 billion in 2020 and is expected
to expand at a compound annual growth rate (CAGR) of 11.6% from 2021 to 2028. (21)

4.5 Safety and Regulation required for CAM practices

Acupuncture

The guidelines of WHO on Basic Training and Safety in Acupuncture mandate a system of
examination and licensing to ensure competency and to prevent unauthorized acupuncture practice.
In addition, there is supervision and monitoring, which includes:
· a period of supervised practice after training.
· monitoring of the performance of the trainees individually and as a group.
· evaluation of the benefits (or otherwise) of including acupuncture in primary health care. (22)

Several large prospective surveys have established its safety in Japan, the UK and Germany. The data
from about 2.2 million treatment sessions suggest the maximum risk of serious harmful incident is
1:76,000 patients treated. Similarly, a prospective survey of 50,276 cervical manipulations identified
no serious harmful incidents. These data suggest the risks of CAM could be ranked as ‘very low’.(23)

Homeopathic medicine

There is no legal regulation of homeopathic practitioners.

However, the FDA intends to focus its enforcement authorities on the following kinds of products:
· with reported safety concerns.
· that contain or purport to contain ingredients associated with potentially significant safety
concerns.
 · for routes of administration other than oral or topical, e.g., for use as an injection or taken
nasally.
· that claim to treat or prevent serious and/or life-threatening diseases and conditions, such as
cancer.
· marketed to vulnerable populations, including children, pregnant women, and the elderly.
· with significant quality issues.(24)

Homeopathic products are highly diluted and appear to present little risk. Therefore, large sample
sizes, possibly requiring international collaborations, are required if precise inferences are to be made
from surveillance studies.
Homeopathic remedies are generally considered safe so patients may increase the dose, risking
overdose with non- homeopathic ingredients, such as ‘non-active’ solvents, up to toxic levels.
Furthermore, risk may arise from ‘mistaken identity’, where e.g., herbal and other medicines are
described as homeopathic to make them look safer. Deliberate contamination during preparation
constitutes another risk.(23)

Aromatherapy

The FDA regulates aromatherapy products mostly based on how they are intended to be used. The
FDA determines a product's intended purpose based on factors such as claims made in the labeling,
on websites, and in advertising. (25)
The use of aromatherapy has grown so rapidly in the recent years, and will continue to do so, the need
for suitable training has become apparent. Training to an acceptable level in aromatic therapy is
needed for safety and effectiveness. (26)

Aromatherapy training qualifies therapists to use essential oils mainly in high dilution (not usually
exceeding 5% concentration, although there are exceptions in emergencies such as minor burns and
bruises) and usually in conjunction with massage. Essential oils can be used for chronic conditions
such as rheumatism, bronchitis, certain forms of arthritis, and disorders such as constipation,
headaches, and skin conditions. Essential oils have been used on the wards under some circumstances
to replace secondary drugs or have been utilized in order to avoid these drugs being given in the first
place.
Essential oils are strong powerful agents and they must be treated with respect and caution lest
unwanted effects result from their use. A key principle to consider is synergy. It seems that essential
oils appear to enhance the action of other oils when used together. When blending a mix of oils, not
only is there the benefit of synergy, but also the reduced risk (for an aromatherapist) of using too
much of anyone oil which used alone may perhaps have unwanted effects. For example, peppermint,
when in a blend (or used in a dilution of 0.5%), is coding and anti-irritant. However, when used on
its own the effect can be exactly the opposite, as happened when a nursing assistant put 20 drops of
the oil in a patient's bath to 'increase the effect' but caused severe irritation to the patient. Lavender
when used on its own may stimulate rather than relax if the quantity of essential oil used is too high.
This has been the experience of several therapists, and This is less likely to happen if used in a
synergistic mix with other oils as the amount of lavender in the mix will be low. The indications and
contraindications for use of theses specific oils are very much a matter of training; the more
knowledgeable the therapist, the more competent and confident they will be in the choice of oils for
a beneficial outcome.(26)

5.0 Conclusion
To conclude, Integrative medicine is a larger meaning and mission than CAM, as it views patients
as whole people with minds and spirits as well as bodies. IM is used for many reasons by people
mainly when they have doubts about conventional treatments. Healthcare actors have established
many modules of IM that they found useful. IM prevalence results show that it is commonly used and
acknowledged by many countries. Even though IM practices have become commonly used for years,
clinical trials, the mechanisms of action of some herbs, and determining doses and routes of
administration still challenge IM. Organizations around the world have established some guidelines
for the safety of CAM practices and organized the practices that have been used in IM.
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