COMPLEMENTARY ALTERNATIVE

MEDICINE(CAM)

Here and in the world

SUMMARYComplementary and Alternative Medicine..................................................................................................3

CAM Costs Overall...............................................................................................................................3

Figure 1 and Figure 2 Combined Combined Total Health Care Spending and Out-of-Pocket Spending Graphic.........................................................................................................................................4

CAM's Part of Total Health Care Costs.............................................................................................................4

Figure 3 CAM Out-of-Pocket Spending: Self-Care* vs. Practitioner Costs....................................................5

CAM Use by U.S. Adults and Children..............................................................................................................6

Complementary and Alternative Medicine: What People Aged 50 and Older Discuss With Their Health Care Providers...............................................................................................................................................................6

Introduction..........................................................................................................................................................6

Methodology........................................................................................................................................................7

CAM Use...........................................................................................................................................................7

Figure 1. Type of CAM Used in the Past 12 Months.....................................................................................8

Figure 2. Education Level and Type of CAM Used in the Past 12 Months....................................................9

The National Health Interview Survey and CAM Use Among People 50+........................................................9

Figure 3. CAM Use in the Past 12 Months Among U.S. Adults, by Age Category4......................................10

Reasons for CAM Use.....................................................................................................................................10

Figure 4. Reasons for CAM Use..................................................................................................................11

Specific Information Discussed.......................................................................................................................11

Figure 8. Topics Discussed by Health Care Provider...................................................................................12

Primary Sources of Information About CAM Treatments..............................................................................12

Figure 10. Primary Source of CAM Information.........................................................................................13

Use of Prescription Medications....................................................................................................................13

Figure 11. Number of Prescription Medications Currently Taken..............................................................14

Figure 12. Number of Prescription Medications Currently Taken by CAM Users......................................14

Who Uses CAM Most......................................................................................................................................15

CAM Therapies Used the Most.......................................................................................................................16

CAM Use Among Children..........................................................................................................................16

Review of Research Shows, Overall, Acupuncture Did Not Increase Pregnancy Rates with IVF........................17

Natural Medicine: The Future of Careers in Global Health.........................................................................18

Over 50% of European adults and children use CAM..................................................................................24

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The use of complementary and alternative medicine in the United States

Complementary and Alternative Medicine

Also called: CAM

Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard care. Standard care is what medical doctors, doctors of osteopathy, and allied health professionals, such as nurses and physical therapists, practice.

Complementary medicine is used together with standard medical care. An example is using acupuncture to help with side effects of cancer treatment.

Alternative medicine is used in place of standard medical care. An example is treating heart disease with chelation therapy (which seeks to remove excess metals from the blood) instead of using a standard approach.

The claims that CAM treatment providers make can sound promising. However, researchers do not know how safe many CAM treatments are or how well they work. Studies are underway to determine the safety and usefulness of many CAM practices.

CAM Costs OverallAccording to the NHIS survey, 83 million U.S. adults spent $33.9 billion out-of-pocket on visits to CAM practitioners and on purchases of CAM products, classes, and materials. In total, there were approximately 354 million visits to CAM practitioners and approximately 835 million purchases.

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Figure 1 and Figure 2 CombinedCombined Total Health Care Spending and Out-of-Pocket Spending Graphic

CAM's Part of Total Health Care Costs

At $33.9 billion, CAM accounts for approximately 1.5 percent of total health care expenditures and 11.2 percent of total out-of-pocket expenditures on health care in the United States. See Figure 1 above.

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The $14.8 billion spent on nonvitamin, nonmineral, naturalproducts is equivalent to approximately one-third of totalout-of-pocket spending on prescription drugs ($47.6 billion), and the $11.9 billion spent on CAM practitioner visits is equivalentto approximately one-quarter of total out-of-pocket spendingon physician visits ($49.6 billion)

Figure 3 CAM Out-of-Pocket Spending: Self-Care* vs. Practitioner Costs

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* Totals for nonvitamin, nonmineral, natural products and homeopathy include both CAM practitioner costs and costs of purchasing CAM products. Totals for massage and chiropractic and osteopathic manipulation are only CAM practitioner costs. Totals for yoga, tai chi, and qi gong classes are only the cost of purchasing CAM products.

CAM Use by U.S. Adults and Children

Percentage of U.S. adults in 2002 vs. 2007 and children in 2007 who used complementary and alternative medicine (CAM) in the past 12 months. The figures show that CAM use among adults has remained relatively steady from 2002 to 2007.

Complementary and Alternative Medicine: What People Aged 50 and Older Discuss With Their Health Care Providers

IntroductionDo Americans aged 50 and older discuss the use of complementary and alternative medicine (CAM) with their health care providers? What do they talk about—or why don't they? To help answer these questions, in October 2010 AARP and the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health partnered on a telephone survey. The survey builds on a similar study conducted in 2006.

Use of CAM is widespread. The 2007 National Health Interview Survey, a nationwide Government survey, found that 38 percent of U.S. adults reported using CAM in the previous

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12 months, with the highest rates among people aged 50–59 (44 percent)1. The NHIS data also revealed that approximately 42 percent of adults who used CAM in the past 12 months disclosed their use of CAM to a physician (M.D.) or osteopathic physician (D.O.)2. Because many adults also use over-the-counter medications, prescription drugs, or other conventional medical approaches to manage their health, communication between patients and health care providers about CAM and conventional therapies is vital to ensuring safe, integrated use of all health care approaches.

CAM is defined as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. CAM includes such products and practices as herbal or dietary supplements, meditation, chiropractic care, and acupuncture.

MethodologyAARP commissioned SSRS, an independent research company, to conduct a telephone survey to assess the use of CAM among people 50 and older and the circumstances under which they discuss such use with their health care providers. Questions covered the following topics:

Whether respondents had used various types of CAM in the past 12 months or ever, and for what purposes

Whether they had discussed CAM with their health care providers What they discussed or why they had not had a discussion Who initiated the discussion Their primary source of information about CAM Their current use of prescription medications.

Interviews were conducted October 13–26, 2010, with a random sample of 1,013 people aged 50 and older. Responses were weighted to reflect the U.S. population of that age. The survey’s overall margin of error is plus or minus 3.1 percentage points at the 95 percent confidence level. The response rate for the survey was 11 percent. Where possible, comparisons were made with a similar study conducted in 2006 with 1,559 respondents aged 50 and older and a margin of error of plus or minus 2.48 percentage points at the 95 percent confidence level

CAM Use

In the AARP/NCCAM survey, just over half (53 percent) of people 50 and older reported using CAM at some point in their lives, and nearly as many (47 percent) reported using it in the past 12 months. Herbal products or dietary supplements were the type of CAM most commonly used, with just over a third (37 percent) of respondents reporting their use, followed by massage therapy, chiropractic manipulation, and other bodywork, used by around a fifth (22 percent) of respondents (Figure 1).

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Figure 1. Type of CAM Used in the Past 12 Months

*Base: All respondents (n=1,013); sampling error = ±3.1 percentage points; respondents could choose more than one answer.

Source: AARP/NCCAM Survey of U.S. Adults 50+, 2010

Some demographic groups were more likely to use CAM than others:

Women were more likely than men to report using any form of CAM in the past 12 months (51 vs. 43 percent) as well as two particular types: herbal products or dietary supplements (41 vs. 33 percent) and massage therapy, chiropractic manipulation, or other bodywork (27 vs. 16 percent).

In most cases, the use of CAM increased with education. As Figure 2 illustrates, those who had attended or graduated from college were significantly more likely than those who had a high school education or less to use every form of CAM with one exception: Those who graduated from college were not significantly more likely than those with a high school education or less to use naturopathy, acupuncture, or homeopathy.

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Figure 2. Education Level and Type of CAM Used in the Past 12 Months

*Base: All respondents (n=1,013); sampling error = ±3.1 percentage points; respondents could choose more than one answer.

Source: AARP/NCCAM Survey of U.S. Adults 50+, 2010

Though relatively few respondents used mind/body practices or alternative medical systems, about twice as many in the younger age group did so.

o Eleven percent of people aged 50-64 reported using mind/body practices including hypnosis and meditation, compared with 5 percent of those 65 and older.

o About 7 percent of those aged 50-64 reported using naturopathy, acupuncture, or homeopathy, compared with 3 percent of those aged 65 and older.

The National Health Interview Survey and CAM Use Among People 50+

The National Health Interview Survey (NHIS) provides the official Government estimates of CAM use. NHIS is a nationally representative survey of the civilian noninstitutionalized household population of the United States. The survey, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, is done through in-person interviews. Questions about CAM usage were included in NHIS in 2007. Over 23,000 adults were asked these questions. Overall, 38 percent of U.S. adults reported using CAM in the previous 12 months, with the highest rates among people aged 50-59 (44 percent).

As Figure 3 illustrates, CAM usage peaks from 50-59 and then begins to decline with age. Among all NHIS respondents aged 50 and over, approximately 39 percent3 reported using CAM in the past 12 months.

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Figure 3. CAM Use in the Past 12 Months Among U.S. Adults, by Age Category4

*Base: All adult respondents 18+ (n=23,393)

Reasons for CAM Use

When those who used CAM were asked why they used these approaches, the most common reasons were to prevent illness or for overall wellness (77 percent) or to reduce pain or treat painful conditions (73 percent) (Figure 4). Other popular uses were to treat a specific health condition (59 percent) or to supplement conventional medicine (53 percent).

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Figure 4. Reasons for CAM Use

*Base: Respondents who used CAM in past 12 months or ever (n=539); sampling error = ±4.2 percentage points; respondents could choose more than one answer.

Specific Information Discussed

As shown in Figure 8, respondents said their health care providers most often discussed:

the potential of interactions between CAM and other medications or treatments (44 percent) advice on whether to pursue CAM treatments (41 percent) the effectiveness of CAM therapies (41 percent), what type of CAM to use (40 percent) the safety of CAM therapies (38 percent).

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Figure 8. Topics Discussed by Health Care Provider

*Base: Respondents who have discussed CAM with a health care provider (n=345); sampling error = ±5.3 percentage points; respondents could choose more than one answer.

Source: AARP/NCCAM Survey of U.S. Adults 50+, 2010

Those with a high school education or less were more likely than college graduates to report that their health care provider had discussed how the CAM therapy might interact with other medications or treatments (50 vs. 35 percent). No other demographic differences were noted

Primary Sources of Information About CAM Treatments

People aged 50 and older who use CAM get their information about it from a variety of sources, as Figure 10 shows. They are most likely to learn about CAM from family or friends (26 percent), followed by the Internet (14 percent), their physician (13 percent; 21 percent for all health care providers), publications including magazines, newspapers, and books (13 percent), and radio or television (7 percent). College graduates are less likely to report getting information from radio and television (1 vs. 9 percent of those who attended college or have less education); no other demographic differences were found. Only one significant difference exists in the sources they consulted in 2010, compared with 4 years earlier: they are more likely to turn to the Internet in 2010 than in 2006 (14 vs. 10 percent).

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Figure 10. Primary Source of CAM Information

*Base: Respondents who used CAM in past 12 months or ever; 2010: n=539, sampling error = ±4.2 percentage points; 2006: n=1005, sampling error= ±3.1 percentage points

Use of Prescription Medications

Overall, four out of five respondents (78 percent) reported taking one or more prescription medications (Figure 11). Younger respondents were less likely to take prescription medications: Of those aged 50–64, 1 in 4 (28 percent) reported taking no prescription medications, compared with 1 in 10 (10 percent) of those aged 65 and older. In addition to any CAM therapies they take, 77 percent of people who have used CAM in the past 12 months reported taking one or more prescription medications (Figure 12).

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Figure 11. Number of Prescription Medications Currently Taken

Source: AARP/NCCAM Survey of U.S. Adults 50+, 2010

Figure 12. Number of Prescription Medications Currently Taken by CAM Users

Source: AARP/NCCAM Survey of U.S. Adults 50+, 2010

CAM users who also take prescription medications were more likely to report that they had discussed CAM with a health care provider. Sixty-four percent of those who have used CAM in the past 12 months and reported currently taking prescription medicines said they have discussed CAM with a health care provider; among those who used CAM in the past 12 months but said they take no prescription medicines, 51 percent reported discussing CAM with a health care provider.

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Who Uses CAM Most

People of all backgrounds use CAM. However, CAM use among adults is greater among women and those with higher levels of education and higher incomes. Figure 2 shows the percentage of people using CAM by age.

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CAM Therapies Used the Most

Nonvitamin, nonmineral natural products are the most commonly used CAM therapy among adults. Use has increased for several therapies, including deep breathing exercises, meditation, massage therapy, and yoga.

CAM Use Among ChildrenThe 2007 NHIS asked selected adult respondents about CAM use by children in their households. Overall, approximately 12 percent of children use some form of CAM. Use is greater among:

Children whose parents used CAM (23.9%) Adolescents aged 12-17 (16.4%), compared to younger children White children (12.8%), compared to Hispanic children (7.9%) and black children (5.9%) Children whose parents had higher education levels (more than high school: 14.7%) Children with six or more health conditions (23.8%) Children whose families delayed conventional care because of cost (16.9%)

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Review of Research Shows, Overall, Acupuncture Did Not Increase Pregnancy Rates with IVFAn analysis of research conducted on acupuncture as an adjuvant (booster) treatment to in vitro fertilization (IVF) found that, overall, acupuncture did not increase pregnancy rates. However, acupuncture did seem to increase pregnancy success rates at IVF clinics with baseline pregnancy

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rates that were lower than 32 percent. This review, funded in part by NCCAM, was published online in the journal Human Reproduction Update.

The review analyzed 16 randomized controlled clinical studies (4,038 participants) from around the world since 2002 that compared actual acupuncture with simulated (sham) acupuncture or no additional treatment. Actual acupuncture consisted of one to three treatment sessions of needling at traditional points (and, in some trials, at tender points). In all trials acupuncture was given within one day of the IVF procedure. The primary outcome was clinical pregnancy rates.

When all the trials were combined, the reviewers found no statistically significant improvement in the rates of clinical pregnancies, ongoing pregnancies (pregnancies beyond 12 weeks of gestation), or live births between women receiving actual acupuncture and the control groups. The reviewers observed heterogeneity (i.e., variability) between studies in the effects of actual acupuncture, with noticeably larger effects on clinical pregnancy rates in one subgroup: IVF clinics that had lower pregnancy rates. For example, one potential factor for this may be related to the number of embryos transplanted per cycle—fewer typically are transferred per cycle in European countries compared to IVF practices in the United States. However, the authors noted that this finding could have various explanations and needs further study. They also suggested that acupuncture could benefit IVF patients beyond potentially improving rates of IVF pregnancy success, noting that it is relatively safe and inexpensive and may aid these patients in coping with the emotional and psychological challenges related to IVF and fertility.  

Natural Medicine: The Future of Careers in Global Health Health care practitioners are laboring hard to manage the symptoms of today's ailing global health care system. As medical costs and the prevalence of chronic illness continue to rise internationally, a growing number of experts recognize that a more preventative, integrative model of health care may be the solution.

In 2006, US$2.1 trillion was spent on medical care in the United States. At least 75 percent of this went toward treating chronic diseases, such as heart disease and diabetes, which are preventable or even reversible through diet and lifestyle changes.

The current model of allopathic medicine widely practiced in North America today is based upon managing symptoms. This approach to medicine certainly has its place in the healthcare arena and an incredible number of scientific breakthroughs have taken place through this model of care. However, top-notch medical research and leading-edge surgical techniques alone are not effective when millions continue to suffer from debilitating chronic disease.

Natural approaches to health care, such as naturopathic medicine, nutritional counseling, acupuncture and Oriental Medicine, and psychological counseling are both medically effective and cost-effective. These modalities emphasize patient-focused care and provide the opportunity to make affordable, quality health care available to those who most need it.

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In fact, studies show that an approach to health care that integrates natural, minimally invasive methods such as plant-based diets, yoga, meditation, acupuncture and psychosocial support, may stop or even reverse the progression of many chronic conditions. It is proven to prevent and provide relief from many conditions, including allergies, asthma, diabetes, heart disease, chronic pain and fatigue, depression, and digestive disorders, as well as help patients manage illnesses such as cancer and HIV/AIDS.

Growing in popularity throughout North America, different forms of Complementary and Alternative Medicine (CAM) are commonly used in conjunction with allopathic medical techniques. According to a 2007 survey conducted by the National Institutes of Health (NIH), approximately 38 percent of adults and approximately 12 percent of children are using some form of CAM therapy in America. A 2002 study published in the American Journal of Public Health found a similar trend in CAM usage among Canadians and Americans.

Pursuing an education in natural medicine is a great way to personally effect a positive change in the health of communities around the world. Enrolling in a comprehensive natural health sciences program that combines the best of eastern and western medicine will prepare future practitioners to bring their patients healthcare that changes their lives and has the power to shift the global health paradigm.

An important tool in reversing the chronic disease epidemic, CAM is poised to play a major role in the future of medicine. An education in this field prepares students to become naturopathic doctors, nutritionists, psychologists, midwives, herbalists or exercise physiologists. When training to become a natural health care provider, students learn how to look for and find the cause of an illness rather than just treat the symptoms. They are taught to explore a patient's entire health care picture, including issues related to lifestyle, history and diet, from a holistic perspective that recognizes the body's innate ability to heal itself.

Alternative medicine in Europe ( OVERVIEW )Despite the advances in Western medicine, up to one in three people in populations served by this medical system are seeking some form of unorthodox care each year, and Europe is no exception. Patients have driven this change, to the point where complementary and alternative medicine (CAM) is the second biggest growth industry in Europe. Often patients have to rely on the growing numbers of CAM practitioners with a variable standard of care that ranges from excellent to dangerous. Many practitioners work without regulation or even work illegally. Many orthodox health care professionals have shared their patients' concerns. Over the last 15 years, these practitioners have moved from silent interest to open enquiry and growing use. For example, approximately one in five of Scotland's general practitioners have received basic training in integrating homeopathy with orthodox practice. The demand for CAM is in part a search for a broader range of therapies, but is also a call for a different approach to care, with less emphasis on drugs, and a more whole-person approach. Mostly, people look to CAM when orthodoxy has failed. But CAM is also increasingly becoming a first-line intervention for some, because of the worry about the side effects of conventional treatments and a perception that orthodoxy has become dehumanized. With some exceptions, research is still in its early stages and lacks infrastructure. Patient satisfaction, empirical clinical outcome, and cost are beginning to be emphasized over mechanism of action or explanatory models. Recent official reports are calling for national and European-level enquiry and response. Future development is likely to

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emphasize integrative care. The challenge is to create better medical systems, with a whole-person emphasis, calling on a broader range of approaches than is currently orthodox. We seem to need a reunion of the art and science of medicine.

CAM in Europe Few European countries have national policies for CAM. Other than for herbal and homeopathic medicines there are no EU regulations governing CAM. Variations in definitions and categorizations of CAM therapies render regulation a challenge as does insufficient knowledge among policy makers of the potential contribution of CAM to healthcare.

There are substantial differences in the way that CAM is recognised, practised and regulated across EU member states, with differences again between the CAM therapies. Some form of regulation exists in 18 out the 29 EU and EEA countries, although there is considerable variation. EUROCAM and especially the CAM doctors association CAMDOC as well as the practitioners organization EFCAM are working to promote the need for a statutory regulation of all those working in the CAM field as well as for the availability of all CAM medicinal products.

CAM has begun to receive greater attention from the European Commission in recent years, with funding being allocated to research and more activity within the institutions including an informal CAM Interest Group within the European Parliament. The European Commission has started a regular dialogue with CAM stakeholders and some CAM products are covered by existing legislation both in the medicines and in the food field. The European Medicines Agency (EMA) is also undertaking activities in the field of CAM.

Statistics about CAM in Europe

SummaryThe most commonly used CAM therapies in Europe that are practised by medical doctorsare acupuncture, homeopathy, phytotherapy, anthroposophic medicine, naturopathy,Traditional Chinese Medicine, osteopathy and chiropractic.Due to a great variety of medical cultures and traditions in different parts of Europe, CAMlooks back on a well-established tradition in some countries or is hardly recognized andavailable in others.

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The regulatory status of CAM is complicated by the different models applied in the EUMember States to provide medical services in their respective countries. CAM is primarilyprovided by physicians in Middle and Southern Europe, whilst the practice of CAM outsideof regulated health care is illegal and violations are considered an offence. By contrast, inNorthern Europe the practice of CAM by non-medically qualified practitioners is allowedwhich has led to a situation where treatment providers outside of the established healthservice constitute the core CAM providers.The extent to which countries have established a statutory regulation of CAM and how suchregulation is performed varies widely. Some countries have government-administeredregulations or laws about the practice of CAM in general, some regulate specific CAMtherapies, while still others have no CAM regulation at all.In 18 of 29 EU and EEA countries specific CAM therapies are statutorily regulated althoughwide variations exist throughout Europe regarding the types of CAM that are regulated. Insome countries some CAM therapies are recognised as specific medical qualifications.In a few countries diplomas for doctors who have taken a full course of a particular CAMmodality are issued and recognised by the national medicalassociations/chambers/councils. However, there is no mutual recognition of diplomasamong the various Member States, which impedes the free movement of CAM doctors.Approximately 180,000 medical doctors in the European Union have taken training andeducation in one or more CAM modalities.Familiarisation courses about CAM therapies are provided in the medical undergraduatecurriculum as a part of a course on Complementary and Alternative Medicine in severalcountries. These courses are optional in most countries, obligatory in some.Postgraduate training courses in specific CAM therapies are provided to doctors at severaluniversities in the majority of EU Member States, in other countries at private teachingcentres only.Professorial chairs of CAM exist in at least 9 EU Member States, in some Member States alsochairs in a specific CAM therapy.

IntroductionComplementary and alternative medicine (CAM) is becoming increasingly popular inEurope with up to 65% of the population reporting that they have used this form ofmedicine. Approximately 30-50% of the European population use CAM as self-support and10-20% of the European population has seen a CAM physician/practitioner within theprevious year.The most commonly used CAM therapies in Europe that are practised by medical doctorsare acupuncture, homeopathy, phytotherapy, anthroposophic medicine, naturopathy,Traditional Chinese Medicine, osteopathy and chiropractic. The popularity of the individualtherapies, however, differs widely between countries. This diversity is both a challenge forexamining the state of CAM in Europe and an opportunity since its inherent plurality givesEurope a unique richness and leading position in the world in terms of the variety ofapproaches, high quality, integrated, holistic and patient oriented healthcare.The regulatory status of CAM in Europe reflects the diversity of acceptance, use andavailability of these treatment approaches in the EU Member States. Due to a great variety ofmedical cultures and traditions in different parts of Europe, CAM looks back on a well established tradition in some countries or is hardly recognized and available in others.

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Models of statutory regulationThere are three main models used to regulate the practice of medicine, namely directgovernment-administered regulation, government-sanctioned self-regulation andindependent self-regulation1. These models differ in the depth of direct governmentinvolvement and are often used in tandem with other acts, which may regulate certainaspects of the health service and medical practice.1. Direct government-administered regulationIn most European countries the government authorises, registers and supervises the healthprofessionals. The authorities can withdraw the authorisation of health professionals if thelaw is violated. This implies that the government, through the appropriate authorities,decides to what extent the use of CAM by regulated health professionals can be designatedas “responsible professional conduct”.2. Government-sanctioned self-regulationIn some countries the law delegates the tasks of authorisation, registration and supervisionof health professionals to the national medical associations. This implies that the nationalmedical associations decide to what extent the use of CAM by authorised healthprofessionals can be designated as “responsible professional conduct”.3. Independent self-regulationSome federations of CAM providers are developing what they call “self-regulation”.“Self-regulation” is a process in which associations of individual therapies develop their ownstatistics, educational programmes, code of ethics, research programmes and standards ofcompetence. In some countries, self-regulation is required for an association to be approvedby the government. A “registered” CAM provider must have a membership in agovernment-approved providers’ federation.

Different models of providing medical services in EuropeAccording to the Declaration on Professional Autonomy and Clinical Independence of theWorld Medical Association (2008) individual physicians ‘have the freedom to exercise theirprofessional judgment in the care and treatment of their patients without undue influence byoutside parties or individuals’. However, CAM therapies usually do not have the sameregulatory status as conventional medicine. They exist largely outside the institutions whereconventional health care is taught and provided and in some countries the medicalassociations have even enforced strict regulations that thwart the practice of CAM bymedical doctors, eg in Sweden and Slovenia.CAM is primarily provided by physicians in Middle and Southern Europe, the practice ofCAM outside of regulated health care is illegal and violations are considered an offence. InNorthern Europe anybody may provide CAM whilst only specific medical acts (e.g. treatingpeople for infectious diseases, performing surgery, administering anaesthetics, prescribingdrugs that require a prescription, giving injections, using X-ray) are restricted to medicaldoctors with a university degree, although the range of these medical acts may differ fromcountry to country. This implies that the practice of CAM by non-medically qualifiedpractitioners is allowed which has led to a situation where treatment providers outside of theestablished health service constitute the core CAM providers.In Hungary and Slovenia the law allows some CAM modalities to be practiced by nonmedically

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qualified practitioners; some only by medical doctors. In Slovenia homeopathy,acupuncture and chiropractic/osteopathy are only permitted to medical doctors, in Hungaryhomeopathy, anthroposophic medicine, traditional Chinese medicine and acupuncture,chiropractic/osteopathy, ayurvedic medicine and traditional Tibetan medicine.

Findings (Reliability)- StatisticsThere is a lack of reliable data on the prevalence of CAM.However, use of herbal medicine was the most frequently reported use of CAM. Musculoskeletal problems were the most reported condition.While there are a few rigorous prevalence studies that are based on nationally representative samples, the vast majority are small and of poor quality. Most EU countries do not have any data at all. Reported prevalence rates of CAM use were between 0.3% and 86%. We were unable to calculate the overallprevalence rate for herbal medicine, homoeopathy, chiropractic, acupuncture or reflexology by either country or across the EU or to differentiate between practitioner (doctor) based prescriptions and over the counter purchases of homeopathic and herbal medicines.Prevalence rates of the main therapies in use were reported as follows:

• Herbal medicine (31 studies): prevalence rates varied from 5.9 – 48.3% of the population studies. However herbal medicine was not well defined (it may be included in naturopathy, folk medicine or traditional Chinese medicine) and variously categorized as medical herbalism, herbal remedies, herbal teas, phytotherapy. Some specific herbs were reported by name such as St John’s Wort.

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• Homeopathy (25 studies): prevalence rates varied from 2 – 27% of the populations studied.

• Chiropractic (17 studies): sometimes reported as “Chiropractic or osteopathy” (1 study), as one of a group of CAMs (4 studies) and as “manual or manipulative treatments” (2 studies). Prevalence rates were 0.4 – 20.8% of the populations studied.

• Acupuncture (14 studies): was poorly defined. Prevalence rates were 0.44 – 23% of the populations studied. Eight further studies reported acupuncture as part of groups of CAMs.

• Reflexology (11 studies): and in a group of CAMs in one other study. Prevalence rates varied from 0.4 – 21% of the populations studied.

• Dietary supplements: calcium supplement use was reported in 9 studies. Use of all other dietary supplements, vitamins, minerals, fish oils, glucosamine and other products was reported heterogeneously in groups, singly or combinations of supplements in 28 papers. It was not possible to distinguish whetherthe dietary supplements were bought over the counter or prescribed at consultations.

CAM provision in Europe comprises health care practitioners and physicians with different healing attitudes, medical background, training, certification, and practice. Data are only available if they are registered in any specific body open to the public, and are therefore scarce, scientific publications are almost lacking completely. Both medical and non-medical practitioners play an important role in the provision of CAM within the healthcare system in Europe. CAM provision in the EU27+12 is maintained by more than 150,000 registered medical doctors (MDs) with additional CAM certification and more than 180,000 registered and certified non-medical CAM practitioners. This suggests up to 65 CAM providers (35 non-medical practitioners and 30 physicians) per 100,000 inhabitants, compared to the EU figures of 95 general medical practitioners per 100,000 inhabitants. Acupuncture is the most frequently provided method (53% of all practitioners) with 80,000 physicians and 16,000 non-medical practitioners trained in the therapy, followed by homeopathy (27% – 45,000 and 4,500, respectively). These two disciplinesare both dominated by physicians. Herbal medicine and manual therapies are almost exclusively provided by non-medical practitioners.Naturopathy, on the other hand, is dominated by 15,000 (mostly German) physicians, as is anthroposophic medicine (4,500) and neural therapy (1,500). CAM provision in Europe has not yet gained governmental interest at large; state funded research based knowledge is mainlyavailable for Denmark, Germany, Norway, Switzerland, and the UK. This calls for more research in this field throughout the EU and associated countries.

Over 50% of European adults and children use CAM A recent European review, performed by combining data from published surveys with expert perspectives, indicates that CAM appears to be popular not only among adults in Europe, but also for children.

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CAM statistics

All European countries with a minimum of 5 million habitants were initially included for which any data about CAM use in children were published in the last 10 years (29 countries), then expanded to include 2 smaller countries. Corresponding authors from these publications were contacted in each country, and they were asked to provide information about paediatric CAM use in their countries.

Limitations created by a lack of representative studies, varying definitions of CAM use, and what qualifies as CAM in different countries was partially overcome by integrating local experts to summarise information available only in the national language and provide their perspectives about CAM availability, quality, use and popularity in their countries using a semi-structured questionnaire. Local and international published surveys were summarised, and the prevalence of CAM use was extrapolated.Data from 20 European countries were available, representing 69% of the European population. Some data about CAM use by the general population were available for 90% of the examined countries, whereas peer-reviewed published surveys were available for only 60%. The authors extrapolated that 56% (range: 10—90%, adjusted for population size) of the European population in general had used CAM at least once in the past year. Surveys in CAM use by children were available for 55% of the investigated countries. The extrapolated prevalence of CAM use by children in Europe was 52% (range: 5—90%, adjusted for population size).

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Paediatric CAM experts reported an increasing awareness for and use of CAM in healthcare institutions.

Complementary and Alternative Medicine Practitioners in Europe. Prevalence, Right to Practice, Use and Research.

Complementary and Alternative Medicine, CAM, is the most common term used in Europe to describe a large number of health practices (over 80) based on a holistic view of the person. While there is no universally accepted definition, the following includes key characteristics of CAM practice: CAM utilized by European citizens represents a variety of different healthcare systems and disciplines based on the knowledge, skills, practices derived from philosophies, theories, beliefs and experiences used to maintain health, as well as to prevent, diagnose, improve or treat the health needs of the whole person. CAM disciplines/modalities are mainly used outside conventional medical care, but in many countries some disciplines are increasingly used in conventional medical settings.

Legal and Practice Context In Europe close to 50 CAM modalities are practiced by non-medically trained practitioners that are organised in well established professional associations on the national and European level. There are several more modalities which, to the best of our knowledge at this time, do not have strong professional organisation. Less than 10 CAM modalities are practiced by medical practitioners who have an additional training in the CAM modality. By and large in Europe there is no positive legal right to practice CAM, but there are a small number of exceptions particularly in common law countries. There is an absence of State education and regulatory procedures for professional recognition, again with a small number of exceptions. Practice is often legally “grey”, disguised or hidden, and tolerated or ignored by the authorities. In some countries practice by non-medically trained people is forbidden and hardly exists at all. There is no EU level harmonisation, but there is some restrictive EU regulation of CAM medicines and products. These conditions put a brake on professional development and access to the therapies medicines and products. Practice is almost exclusively private and fee paying, and available only to those with the means to pay. Nevertheless there are millions of users of CAM practitioner services. Where it is legally open to practice, practitioner numbers have grown in response to citizen demand. Where the political and legal climate is less open there is also much “unofficial” successful and effective practice. There is a significant amount of practice in the non regularised part of the market. There is also medical opposition, hostility, negative media comment and an absence of accurate information for potential users. CAM’s safety record is good. But there is insufficient appropriate research and research design leaving CAM vulnerable to often unjustified criticism. Nevertheless, several of the modalities professionally organised are seeking appropriate State regulation. Some have been more successful at negotiation of this than others, so they are more publicly visible.

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Practitioner Numbers No European country has established a comprehensive and reliable system to enumerate practitioners. A number of modalities have established national and European professional organisations with practitioner registers based on effective accreditation procedures. However, the true spread and number of practitioners is difficult to determine at this time. A dedicated study designed to take into account the legally grey conditions of practice described above is urgently needed. In it’s absence the European Federation for Complementary and Alternative Medicine, EFCAM, carried out it’s own survey among modalities with a professional organisation. These numbers are taken from professional registers and can be relied upon. However, no modality organisation in any country in Europe contains all that that modality’s practitioners so the numbers here are less than the total numbers for those modalities. Estimates for all the other modalities are based on general knowledge of the practice of those modalities. EFCAM’s best estimate, therefore, for a total number of CAM practitioners (non-medical) in Europe is: 270,000.

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Commentary The existence of 180,000 non-medically trained practitioners is verifiable from professional association registers and the associations’ accreditation procedures. Another 90,000, approx, are known to exist practising the following modalities not listed above: Alexander technique, Anma, Aromatherapy, Ayuerveda, Bach Flowers, Balneotherapy, Bio-energy, Chi Gung, Colonic Irrigation, Massage (various kinds), Music Therapy, NLP, Nutritional Therapy, Pilates, Reiki, Rolfing, Scenar, Spiritual Healing, Trager, T’ai Chi, Thai Massage, Tuina, Yoga, Watsu and others. Our estimated total is therefore 270,000 plus a further number undetermined right now. No study of the economic value of CAM practice in Europe exists. The following is a projected spend calculation on treatments from known practitioners: 270,000 X 46 weeks X 10 clients/week X 35euro fee = 4.35 billion per annum. This is a projection only as no proper data is currently available.

Reasons for use of CAM Practitioners The following are commonly stated reasons for attending CAM practitioners for general wellbeing and health maintenance

for treatment of chronic illness

for complementary care to conventional medicine in musculoskeletal conditions, cancer, MS and many others

for health awareness, health education and health literacy

for support with self-responsibility for health and self empowerment (user profile early middle aged and up mostly)

for enhanced capacity to cope with serious illness

for it’s cross cutting features: care of whole individual, for being heard, for non-invasive treatment, for safety, for general wellbeing effects alongside effectiveness for specific conditions

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