When it comes to treating pain and chronic disease, many doctors are turning to treatments like acupuncture and meditation—but using them as part of a larger, integrative approach to health.
Back in the 1990s, the word “alternative” was a synonym for hip and forward-thinking. There was alternative music and alternative energy; there were even high-profile alternative presidential candidates like Ross Perot and Ralph Nader. That was the decade when doctors started to realize just how many Americans were using alternative medicine, starting with a 1993 paper published in The New England Journal of Medicine. The paper reported that one in three Americans were using some kind of “unconventional therapy.” Only 28 percent of them were telling their primary-care doctors about it.
I was in high school at the time, and I knew about alternative medicine from my father, a family physician. He’d learned Transcendental Meditation back in medical school, and when I was a child, he began studying Ayurveda, the traditional medicine of India. He never stopped practicing conventional medicine, but he added new things. At home, if I had a persistent sinus infection, he’d put me on antibiotics. But if I had a low-level cold, he’d advise me to drink ginger tea, inhale eucalyptus steam, and eat turmeric with honey. And the school I attended started and ended each day with a group meditation.
Enough Americans had similar interests that, in the early 1990s, Congress established an Office of Alternative Medicine within the National Institutes of Health. Seven years later, that office expanded into the National Center for Complementary and Alternative Medicine (NCCAM), with a $50 million budget dedicated to studying just about every treatment that didn’t involve pharmaceuticals or surgery—traditional systems like Ayurveda and acupuncture along with more esoteric things like homeopathy and energy healing.
Some thought the NCCAM’s work was too far outside the mainstream. “My problem was that they were funding studies on things like distance healing and putting magnets in your mattress to improve arthritis,” Paul Offit, the chief of the infectious-disease division at Children’s Hospital of Philadelphia, recently told me. “There’s no way that ever could have worked. The iron in your blood is not magnetizable.”
Offit criticized the NCCAM in his 2013 book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine, and after that, he said, the center’s director, Josephine Briggs, invited him to meet with her. “She was certainly very nice,” Offit said. “And she assured me that they weren’t doing things like that anymore.”
The idea of alternative medicine—an outsider movement challenging the medical status quo—has fallen out of favor since my youth.
In an email, Briggs confirmed that her center’s mission has shifted over the years. When the NCCAM first launched, she wrote, “this field of research was still in its infancy” and the center “pursued many avenues.” Since that time, she said, it’s become clearer which approaches “hold the most promise [and] are amenable to scientific investigation.”
That change became more pronounced a few months ago, when Congress removed the word “alternative” from the NCCAM’s name, redubbing it the National Center for Complementary and Integrative Health (NCCIH). Offit doesn’t think the new name is much of an improvement. “Integrative, alternative, complementary, holistic—it’s all sales,” he told me.
But I was intrigued by the NIH center’s name change and what it says about a larger shift that’s been going on for years. The idea of alternative medicine—an outsider movement challenging the medical status quo—has fallen out of favor since my youth. Plenty of people still identify strongly with the label, but these days, they’re often the most extreme advocates, the ones who believe in using homeopathy instead of vaccines, “liver flushes” instead of HIV drugs, and garlic instead of chemotherapy.
In contrast, integrative doctors see themselves as part of the medical establishment. “I don’t like the term ‘alternative medicine,’” says Mimi Guarneri, a longtime cardiologist and researcher who founded the Academy of Integrative Health and Medicine as well as the integrative center at Scripps. “Because it implies, ‘I’m diagnosed with cancer and I’m going to not do any chemo, radiation, or any conventional medicine, I’m going to do juicing.’”
Data: CDC Naitonal Health Statistics Report #12; Chart: Lauren Giordano / The Atlantic
After visiting the NIH center and talking to leading integrative physicians, I can say pretty definitively that integrative health is not just another name for alternative medicine. There are 50 institutions around the country that have integrative in their name, at places like Harvard, Stanford, Duke, and the Mayo Clinic. Most of them offer treatments like acupuncture, massage, and nutrition counseling, along with conventional drugs and surgery.
The actual treatments they use vary, but what ties integrative doctors together is their focus on chronic disease and their effort to create an abstract condition called wellness. In the process, they’re scrutinizing many therapies that were once considered alternative, subjecting them to the scientific method and then using them the same way they’d incorporate any other evidence-based medicine.
This approach is forcing the entire medical community to grapple with certain questions: How has the role of a doctor changed over the years? Are there better ways to treat the kinds of health problems that can usually only be managed, not cured? And how do you gather evidence on therapies that involve not only the body but also the mind?
On a recent morning, I drove to the NIH campus in Bethesda, Maryland, to visit the NCCIH’s pain labs. The center began focusing on pain a few years ago, after noticing that most people who used complementary therapies were trying to alleviate conditions like backaches, arthritis, and migraines. There are now five on-campus labs dedicated to this research, and pain studies account for a third of the center’s $124 million budget. (The rest of the funding goes toward a range of outside research, a lot of it dedicated to testing the safety and efficacy of natural products.)
According to a 2011 report from the Institute of Medicine, about 100 million American adults suffer from chronic pain—that means about 40 percent of all people over 18. Bringing them relief costs about $560 to $635 billion in incremental healthcare and lost productivity, making pain a more expensive problem than heart disease, cancer, or diabetes. But there often isn’t a whole lot medicine can do to help. Prescription opioids are highly addictive and get less effective over time, and overdoses can easily turn fatal, so doctors try not to prescribe them long-term. That leaves many millions of people taking non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin. But when they’re used long-term on a daily basis, these drugs can cause serious gastrointestinal problems.
One reason pain is so hard to treat is that it isn’t just physical. It can carry on long after the initial illness or injury is over, and it can shift throughout the body in baffling ways, even lodging in phantom limbs. Two different people can have the same physical condition and experience the pain in dramatically different ways. As the Institute of Medicine report put it, pain flouts “the long-standing belief regarding the strict separation between mind and body, often attributed to the early 17th-century French philosopher René Descartes.”
This may be why so many chronic pain sufferers are drawn to traditional medicine: The Cartesian idea of mind-body duality never found its way into these ancient systems. Acupuncture, for instance, has been shown to help with problems like back, neck, and knee pain. But it’s very hard for science to figure out how it works, since it involves so many components that are mental as well as physical. The technique of inserting the needles, the attitude of the practitioner, the patient’s own attention—all of these are built into the treatment itself. In Acupuncture Research: Strategies for Developing an Evidence Base, researchers note that ancient Chinese physicians saw the mind and body as “necessarily connected and inseparable.”
When a patient’s mind influences a health outcome, this is usually referred to as the placebo effect. The term, which comes from the Latin word for “placate,” doesn’t have positive connotations. In The Canterbury Tales, Placebo is a character who flatters his friend, telling him whatever he wants to hear. In medicine, a placebo is a treatment that only works because people think it will.
It’s very hard for science to figure out how acupuncture works, since it involves so many components that are mental as well as physical.
Lauren Atlas, the director of the NCCIH’s neuroimaging lab, told me she finds it strange when people scoff about a treatment being “just a placebo.” “Because I come to it interested in how expectations affect perception, and pain is the most powerful example of that,” she said. “We’ve known for decades that the placebo effect can engage endogenous opioids—your body’s own pain-relieving substances—to fight pain even without any treatment.”
Atlas’s work focuses on breaking down the placebo effect into a number of separate factors that, altogether, form “a kind of meaning, or schema.” For instance, she’s looking at Pavlovian conditioning—the expectations people develop after they’ve been exposed to the same stimulus over and over again. There’s also verbal instruction—the amount of pain, or pain relief, an authority figure tells the person to expect. “We can measure your body’s physical response just to the instruction alone, using things like skin conductance and pupil dilation,” she said. “We can also measure brain responses just to the instruction alone.”
Drugs like ibuprofen and aspirin reduce pain and swelling, but they can also cause serious gastrointestinal complications over time. (Data: The American College of Gastroenterology; Chart: Lauren Giordano / The Atlantic)
Atlas is also studying the way people feel about their pain. She points out that in some scenarios, a person might be able to tolerate much more pain than usual, even welcome it: getting a tattoo, for instance, or going through the early stages of labor. She compares this subjective element of pain to tasting a glass of juice. “Like pain, taste has that sensory aspect,” she explained. “There’s what the juice tastes like and how strong the taste is, but also whether you like the flavor.” This isn’t just a metaphor: Atlas is doing actual studies that examine the way people process taste and compare it to the way they process pain. “We’re finding that the same brain pathways seem to be involved across a lot of different areas of affective neuroscience, or neuroscience that involves emotion.”
Down the hall at another NCCIH lab, some of Atlas’s colleagues are looking at how specific therapies can make people more pain-tolerant. In a study published last fall, they found that subjects who had been doing yoga regularly for six years or longer could keep their hands submerged in ice water more than twice as long as matched controls. The yoga practitioners also had greater gray matter volume in parts of the brain that deal with pain—the same areas that erode in the brains of chronic pain patients.
One of the authors of that study, Marta Čeko, told me that she and her colleagues asked all the subjects to explain how they tolerated the ice water. They compiled all the answers into a randomized spreadsheet, then asked six outside researchers to assign them to one of nine categories, ranging from “ignores the pain” to “focuses on sensation—observes it without reacting.” The people who gave the first kind of answer were overwhelmingly the non-yogis, while the people who remained aware of the pain, or found ways to reinterpret it, were the yoga practitioners.
After hearing about this research, I wondered—how did the NCCIH researchers define “yoga”? There are significant differences between aerobic Vinyasa, disciplined Iyengar, hot Bikram, and meditative Anusara. Was it the physical exercise that was making the yoga practitioners more pain-tolerant? Or was it an attitude they’d worked to cultivate? Čeko told me the study didn’t make this distinction. She pointed me to another study she and her colleagues published in mid-May, which looked at postures, breathing exercises, and meditation and found that each of these changes the brain in a different way. But she emphasized that the overall pain benefits of yoga seem to come from some combination of all these things.
Čeko acknowledges that she and her colleagues are at the beginning of a long process of teasing apart nebulous ideas. “What we’re doing now is looking specifically at chronic pain patients, trying to understand why some of them modulate pain differently than others,” she said. “If we’re able to find that mechanism—and in them, not just in healthy people—we can better address that impairment. That’s what we’re trying to figure out.”
It’s hard to talk about integrative health without using abstract terms like wellness, vitality, and healing. Most traditional medicine systems are built around these ideas. They start with the assumption that there’s some kind of life force that wards off disease. Then they treat specific illnesses by balancing elements or unblocking energy flow—whatever it takes to get the body back to its natural state of equilibrium.
Modern medicine doesn’t have theories like this. In fact, it was the lack of these philosophies that set physicians apart from the homeopaths and hydropaths who once crowded the American marketplace. Starting around the turn of the 20th century, doctors learned how bacteria and viruses could transmit illness. They studied the systems of the body and all the different ways they could go wrong.
“We have an acute-disease system for a chronic-disease population. The whole approach is to suppress and inhibit the manifestations of disease.”
For a long time, though, the medical profession was so busy treating acute illness that it didn’t put as much attention on preventing heart disease, diabetes, or cancer. Naomi Rogers, a Yale associate professor who teaches the history of medicine, gave me the example of cigarettes. Starting in the 1950s, it was clear that smoking was linked to lung cancer. But even a decade later, Rogers said, “when you went to the doctor’s office, the doctor would have an ashtray. And very often, if you appeared nervous, he would offer you a cigarette. Doctors who smoked themselves used to smoke with their patients to help calm them down.”
There were doctors who thought more deeply about prevention, but their conclusions weren’t usually based on rigorous empirical data. In 1963, Samuel A. Levine, a highly respected cardiologist at Harvard medical school, asserted in The Atlantic that exercise was harmful for patients with heart disease. His argument was based on the large numbers of people who had heart attacks while shoveling snow. (He also noted approvingly that some people might prefer to simply “sit back, smoke a pipe, and just muse” in their spare time.) Years later, studies would show that heart patients who get regular aerobic exercise are less likely to have heart attacks brought on by physical exertion. But after Levine’s article was published, other doctors sent letters to the editor applauding his conclusions.
In the 1970s, medicine went through a radical change. “That was the moment when almost all the vaccines we have today were already in use, and infectious disease suddenly seemed like your grandfather’s kind of topic,” Rogers says. So doctors started focusing their attention elsewhere. “Heart disease was really the first problem that began to make a difference in medical education and in clinical practice. Because it simply was not something that you wanted to wait to identify until someone had that one very scary, potentially death-causing heart-attack moment.”
One response was to develop drugs like statins, beta blockers, ACE inhibitors, and, very recently, a class of drugs called PSCK9 inhibitors. Each of these drugs works by suppressing some process—keeping a particular protein from being formed or stopping a certain stress hormone from entering a receptor. Statins, for example, inhibit an enzyme that plays a crucial role in producing cholesterol. These medications are prescribed widely: About a quarter of all Americans over 45 are currently taking statins.
But drugs have side effects, and in the case of statins, these include fatigue and muscle pain. A 2014 study published in JAMA Internal Medicine suggests that people who take statins tend to exercise less. This means many patients might end up becoming less active because of the statins and actually increase their chances of having a heart attack.
Lauren Giordano / The Atlantic
Several doctors I interviewed for this story mentioned statins as an example of how modern medicine falls short. It’s not that statins don’t work for high-risk patients, they argued—it’s that they’re prescribed much too broadly, based on a few factors such as age, blood pressure, and cholesterol. “High LDL cholesterol in itself doesn’t mean a person is going to develop heart disease,” says Mark Hyman, the director of the Center for Functional Medicine at the Cleveland Clinic (and Bill and Hillary Clinton’s doctor). Before he prescribes statins, he looks at a number of other factors, including the amount of plaque already in the heart, the size of the cholesterol particles, the degree of insulin resistance or pre-diabetes, and the overall level of inflammation in the body. He says this lets him rule out a large number of people who would ordinarily be given the drugs.
The bigger problem, says Hyman, is that most doctors aren’t well equipped to treat chronic disease. “We have an acute-disease system for a chronic-disease population,” he told me. “The whole approach is to suppress and inhibit the manifestations of disease.” Hyman thinks this suppression approach makes sense when you’re trying to solve a sudden flare-up—a high fever, a migraine, or a constriction of the airways during an asthma attack. But he thinks it’s the wrong way to address a problem like heart disease, which develops over time and is so complex that doctors still don’t understand exactly what causes it.
“The goal should be to enhance and optimize the body’s natural function,” he said. “Let’s say a patient comes to me with high blood pressure, irritable bowel syndrome, and eczema. I do not treat each of these separately. Instead, I try to figure out how they might they be connected and identify the root causes. These are all inflammatory disorders. Once we realize this, all the medical boundaries start to break down and we’re able to focus on restoring balance.”
The question is how integrative doctors try to restore balance—and the answer varies. Many of them focus on diet to a degree that goes far beyond the usual guidelines about avoiding salt or trans fat. They’ll look for undiagnosed food sensitivities or hormonal imbalances, with the idea that these problems account for many chronic health complaints and cause even more serious breakdowns over time. There’s a lot of emphasis on intestinal bacteria. “We now know that so many separate things are linked to what’s going on in the gut,” Hyman told me, alluding to a growing body of literature linking the microbiome to everything from cancer to mood disorders.
“Most physicians are not taught about stress-reduction techniques for health.”
Guarneri, the cardiologist who founded the integrative center at Scripps, told me integrative health is highly personalized. At her own La Jolla practice, she prides herself on offering in-depth lab workups and unhurried consultations where she asks patients about everything from environmental exposures to personal relationships. “These are the things that interact with your genes and determine whether or not you stay healthy,” she says. Each patient who comes for one of her comprehensive assessments leaves with a detailed three-to-12-month health plan.
Integrative doctors tend to favor treatments that are—as Briggs, the NCCIH director, put it—“amenable to scientific investigation.” Several of the doctors I interviewed told me they don’t prescribe homeopathic remedies, for instance, because there’s no evidence to support them. That said, they don’t dissuade enthusiastic patients from using them as long as the remedies have at least been proven safe.
When integrative doctors do employ alternative-seeming treatments, it’s usually to manage pain or reduce stress. Guarneri’s practice offers onsite massage therapy, herbal baths, craniosacral therapy, and acupuncture. She says she learned the importance of stress-reduction early in her career.
“Back in the 1990s, I was putting in 750 stents a year,” she says. Then Dean Ornish, one of the first and best-known researchers of lifestyle medicine, asked her to help him with a study. “We took very sick heart patients and taught them yoga and meditation, changed their diet, put them in support groups, and got them exercising. And we started to see a 91 percent reduction in chest pain. We were actually able to reverse plaque in people’s arteries.”
Since then, Guarneri has been convinced that eliminating stress is as important as diet and exercise. “Most physicians are not taught about stress-reduction techniques for health,” she told me. She cited recent research from the American Heart Association journal Circulation. “There’s a five-year study on Transcendental Meditation that’s well controlled and shows a 48 percent reduction for heart attack, stroke, and sudden death. To me that’s medicine. Meditation is medicine.”
After months of speaking to leading integrative doctors and researchers, I found that I was still having trouble summing up exactly what integrative health was all about. It’s not a specialty like obstetrics or endocrinology. There are integrative training programs and certifications out there, but none of them has been universally recognized throughout the medical profession. “At this point it’s really a self-declaration,” Nancy Sudak, the chair of the Academy of Integrative Health and Medicine, told me. “And nobody has a tool kit that includes absolutely everything. It largely depends on who you are as a practitioner.”
Aside from these variations, there’s another reason it’s hard to define integrative health: It doesn’t exist in a vacuum. Its practitioners are part of the same medical establishment as other doctors, going to the same conferences and publishing in the same journals. They’ve influenced and been influenced by major trends in medicine—for instance, the movement toward patient-centered medicine, or the backlash against the overuse of drugs and surgery that the New Yorker writer Atul Gawande calls “the epidemic of unnecessary care.”
Data: CDC Report on Multiple Chronic Conditions Among Adults; Chart: Lauren Giordano / The Atlantic
Sudak says that when she attended an annual meeting of the American Academy of Family Physicians a couple of years ago, she was struck by how her specialty had changed. Instead of just discussing diseases and treatments, her colleagues were focusing on the human side of medicine. “Most speakers led with the relationships they had with their patients, and what a privilege it was to serve people in that way,” she says. “Because family doctors know their patients, we’re more likely to garner meaningful information about their histories—what their jobs are like, what they’re exposed to, how their family relationships are. These are all key factors in health outcomes.”
Reid Blackwelder, the chair of the AAFP, says the principles of integrative health have profoundly influenced his own practice. “Integration is truly the key idea in so much of what we’re trying to do,” he told me. One important element, for him, has been creating an integrated team of experts in his own office, including a psychologist and a social worker. “If a patient comes in with certain kinds of questions, who can I train in my office to answer them? Do I have a pharmacist available who carries herbs and supplements and has the expertise to make sure there’s no drug interaction?”
Blackwelder also makes frequent use of the medical databases installed on his smartphone. He relies on them mostly for checking check drug dosages and interactions, but these days, some of the biggest ones—such as Prescriber’s Letter and Lexicomp—also contain the latest research about complementary therapies. “I was just at a conference of the Massachusetts Academy of Family Physicians. During an evidence-based lecture, a nationally recognized expert mentioned an herb called pelargonium.” He hadn’t heard of that particular remedy, which is used to treat bronchitis and sore throat. “So I quickly looked it up on my phone and got great information about the studies supporting it.”
When Blackwelder teaches family medicine at East Tennessee University, he says he reminds his students to stay open to treatments that once seemed esoteric, as long as they show some promise. “A common homily we tell our students is that in five years, half of what we taught them will be wrong. We just don’t know which half,” he says. “We find things out by remaining inquisitive, being open to exploring new ideas when a question is asked. We should never just say we’ve got it all figured out, because we rarely do.”
At a time when one in two American adults has at least one chronic disease, it’s safe to say there are a lot of things medicine still hasn’t figured out. There are drugs for all kinds of ills and public-health guidelines about food, fitness, and smoking. But when individual patients complain about ongoing headaches, indigestion, or joint pain, doctors often have little to offer.
Medicine is a highly adaptable profession, with new studies constantly challenging the conventional wisdom. But some of the most important changes—from Abraham Flexner’s medical-school reforms to the evidence-based medicine movement of the 1990s—have been cultural ones, based on moments of self-reflection that led the medical community to think differently about its role. Integrative health could prove to be one of those moments. When doctors talk about treating the patient’s “body, mind, and spirit,” it can sound like a feel-good catchphrase. But in fact, there may be no other way to treat diseases that take years to develop and are intimately tied to the ways people think, feel, and live their everyday lives.
Written by Jennie Rothenberg Gritz for The Atlantic, June 25, 2015.
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