Complementary and alternative therapies encompass a broad range of therapeutic modalities that can be integrated into Western medicine. CAM offers patients treatment options, especially when dealing with chronic illness and symptom alleviation. As physicians, the more comfortable and informed we are about CAM, the more effectively we can help our patients make safe and intelligent decisions. As anesthesiologists, we should ask about CAM use during our standard history taking, especially the use of herbs. Knowledge of CAM use can help prevent potential hazards during surgery and can assist with the management of pain, anxiety, and nausea and vomiting.

1. Practices that are not accepted as correct or in conformity with the beliefs of the dominant group of medical practitioners in a society

2. Interventions neither taught widely in medical schools nor generally available in hospitals

B. Categories of CAM Practices. The National Center for Complementary and Alternative Medicine, a subdivision of the National Institutes of Health, has grouped CAM practices into five major subdivisions:

1. Alternative medical systems are complete systems of theory and practice that have evolved in various cultures, mostly before the inception of conventional medicine. An example is traditional oriental medicine, which uses acupuncture, herbal medicine, massage, and qi gong.

a. Acupuncture involves the insertion of fine, solid needles into specific points on the body to produce a therapeutic result. Acupuncture influences the nervous system at multiple levels and causes release of endorphins, serotonin, norepinephrine, and cortisol. Many of these substances reduce inflammation and pain sensation.

2. Mind-body interventions use techniques to facilitate the mind’s ability to affect bodily functions. Examples include hypnosis, meditation, prayer, art therapy, music medicine and therapy, and mental healing.

3. Biologically based treatments overlap with conventional medicine’s use of dietary supplements. They include herbal therapy (see section III), special diets, shark cartilage to treat cancer, and bee pollen to treat autoimmune diseases.

4. Manipulative and body-based methods use movement or manipulation of the body to restore health. Examples include chiropractic medicine, massage therapy, and osteopathic manipulation.

5. Energy therapies focus on energy fields originating within the body (biofields) or from other sources (electromagnetic fields). Examples include qi gong, reiki, and therapeutic touch.

1. Information released by the National Center for Complementary and Alternative Medicine and the National Center for Health Statistics has
estimated that 38.3% of adults and 11.8% of children have used some form of complementary or alternative medicine. The most commonly used modalities include the use of natural products, deep breathing, meditation, and chiropractic/osteopathic manipulation. Total out-of-pocket expense for CAM represents billions of dollars and compares with the money spent on traditional physicians.

2. Most CAM therapies are used for chronic conditions, especially back and neck pain, depression, anxiety, and insomnia. Symptom relief is the main benefit reported. The vast majority of people use CAM in conjunction with conventional therapies.

3. Disclosure rates. Although disclosure rates have been increasing, there are still many patients who do not tell their doctors about the CAM therapies they are using. This places the burden on physicians to elicit this information from their patients, and effectively discussing CAM can be challenging. A physician informed about alternative medicine can help patients avoid dangerous side effects and also help them make safe and intelligent choices.

A. Herbal medicines and phytopharmaceuticals are plants or parts of plants that contain biologically active components. There is tremendous variability in the purity and potency of herbal preparations. The amount of active component can vary widely within the same species depending on growing conditions. Herbal products are sometimes adulterated with foreign substances, including pharmaceuticals, bacteria, and toxic metals. Dietary supplements contain “concentrate, metabolite, constituent, extract, or combination of any ingredient of a vitamin, mineral, amino acid, enzyme or herb.” Vitamins are supplements that contain essential organic compounds or nutrients that are required in small amounts to maintain bodily functions. Homeopathic medications are derived from plant, animal, or mineral sources. It is thought that they stimulate natural defenses in very diluted doses.

B. Herbal medicines are regulated by the U.S. Food and Drug Administration in the category of “dietary supplements” along with compounds such as vitamins and amino acids. The manufacturer does not have to prove efficacy or safety of a compound before it is marketed, and products are not scrutinized via the same stringent testing placed on drugs. Some companies are now using techniques such as chromatography to identify and standardize herbal preparations.

C. The American Society of Anesthesiologists recommends discontinuing herbal remedies 2 weeks before elective surgery. Herbal medications may be dangerous when used in combination with prescription or over-the-counter drugs. They can alter the metabolism of drugs and have been associated with arrhythmias and bleeding. The sale of Ephedra (Ma Huang) was banned by the federal government in 2004 after a review of adverse events including heart attack, stroke, and death. However, ephedra is still available online in a modified form that removes certain alkaloids that technically makes it still legal. There is little evidence in the form of prospective studies or randomized clinical trials documenting the adverse effects of herbal medications used in the perioperative period. Case reports provide most of the evidence for the deleterious effects of herbal medications. For example, four cases of spontaneous intracranial bleeding have been caused by the use of ginkgo biloba. The mechanism could be related to platelet inhibition.

D. It has been estimated that one in five Americans taking prescription drugs is also taking vitamins or herbal supplements. The most frequently used herbs are echinacea, gingko biloba, St. John’s wort, garlic, and ginseng.

E. Commonly used herbs/supplements and possible anesthetic interactions

1. Echinacea (Echinacea purpura, purple cone flower)

a. Uses: for common colds, wounds and burns, urinary tract infections, coughs, and bronchitis (immunostimulation via enhanced phagocytosis and nonspecific T-cell stimulation).

b. Problems and interactions: may cause hepatotoxicity or potentiate hepatotoxic effects of anabolic steroids, amiodarone, ketoconazole, and methotrexate. By inhibiting microsomal enzymes, can precipitate the toxicity of drugs dependent on hepatic metabolism (e.g., phenytoin, rifampin, and phenobarbital). May decrease effectiveness of corticosteroids and cyclosporine.

2. Ephedra (Ephedra sinica, Ma Huang) not approved by FDA

a. Uses: in over-the-counter diet aids; for bacteriostatic, antitussive actions (sympathomimetic with positive inotropic/chronotropic effects; α– and β-adrenergic agonist)