CAM need not be an either/or proposition. Instead, integrating CAM
with conventional medicine may increase the options for your sick patients.
By Marie Rosenthal, MS •Executive Editor
Some veterinarians see complementary and alternative medicine (CAM) as irrational. Others see CAM as an opportunity to increase the choices that a veterinarian who practices conventional medicine can offer patients. CAM does not need to be an either/or proposition. Instead, an integrative approach that combines conventional medical treatments with CAM modalities may be a good approach for some sick patients, according to experts.
“Thinking in terms of complement is important,” says Christina Fuoco, VMD, CVA, who practices acupuncture at the University of Pennsylvania College of Veterinary Medicine and the Queen Village Animal Hospital in Philadelphia. “If veterinarians do what they want from a Western standpoint, treat their patient as they see appropriate from their knowledge and understanding of the disease process and then offer their patients some of the alternatives, they can complement what they are already doing.”
“If someone comes to me and says, ‘My dog is on NSAIDs,’ I amnot going to take the dog off NSAIDs and say, ‘You have to do acupuncture and herbal medicine.’ I am going to say, ‘Okay, let’s integrate that with what I will be doing,’” explains Lisa J. Donato,DVM, CVA, FAAVA, CVT, CVH, CAC, who is chief of alternative medicine at The Center for Specialized Veterinary Care, Westbury, N.Y.
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| Dr. Gene F. Giggleman provides hands-on chiropractic adjustments to a dog with a cast. Chiropractic can be used to treat a range of conditions. |
The use of CAMamong pet owners appears to be fairly widespread, especially for themselves. A recent report by the National Institutes of Health (NIH) found that 7 in 10 adults and 1 in 9 children are receiving CAM. People want these options for themselves and their children and might ask for
CAM modalities for their pets, as well.
Although there are no data about the extent of CAM use in animals, a small study by Susan E. Lana, DVM, MS, DACVIM, at Colorado State University, found that 76% of owners with a dog or cat with cancer reported using CAM on their pet, and nutritional supplements were the most commonly reported therapy.
“I think that public demand for CAM means that as veterinarians, we have to be familiar with what options are available so we can refer owners and guide them to do what is best for their pets,” says Erin O. Bannink, DVM, DACVIM (Oncology), CVA (IVAS), of Oakland Veterinary Referral Services, Bloomfield Hills, Mich., who practices conventional oncology and traditional Chinese medicine.
“The more that veterinarians can learn about CAM, the better,” agrees Donato, who practices chiropractic adjustment, acupuncture, Chinese herbal medicine and conventional medicine. “Veterinarians can no longer put their heads in the sand and say, ‘I am not interested in this, and I don’t care.’ You have to care because the patients are using these treatment methods.”
Among the first to consider CAM options appear to be those who work with patients in pain: surgeons, orthopedists and oncologists. They recognized early that adding CAM to conventional medicine can have positive effects on the pain receptors of pets and people. In fact, the 2008 guidelines for treating human back pain, issued by the American College of Physicians and published in the Annals of Internal Medicine, include acupuncture, chiropractic adjustment and massage therapy, as well as pharmaceutical drugs and, in some cases, surgery.
“Here you have a wholly conventional professional group starting to include CAM therapies in its best practices guidelines for primary care physicians,” says Richard Nahin, PhD, MPH, senior advisor for scientific outreach at the NIH Center for Complementary and Alternative Medicine.
Modalities, such as acupuncture, chiropractic adjustment and dietary supplements, are so common today that they are losing that label of “alternative” in human medicine, Nahin added. One reason these modalities are so widely accepted is that the clinical trials and history behind their use make conventional medicine physicians more comfortable with them.
In animal health, reputable companies also have spent time and effort providing the data to support their supplements and the supplementation of foods. Glucosamine products are given to animals with osteoarthritis. Probiotic products are routinely used for gastrointestinal health, and products containing S-adenosylmethionine (SAMe) are considered mainstream for treating liver conditions. In addition, more veterinarians are becoming certified in acupuncture and chiropractic adjustment, as well as other CAM practices.
These practices are becoming so common in veterinary medicine today that many pet insurance companies cover a number of them, and clients should be told to check the individual policy for their pet — they may get some reimbursement. In this respect, insurance for animals is ahead of the curve of human medicine. Most health insurance policies covering people do not include CAM. Pet insurance coverage is worth mentioning when discussing CAM with a client.
Regardless of a veterinarian’s approach, it is imperative that he or she find out what clients are giving to their dogs and cats, experts insist, to ensure that it is not toxic to the animal, does not interfere with any conventional medications the animal is taking and is being consumed in the correct amount for that animal. Often clients fail to share this information with their veterinarians.
This is a common problem among physicians, too. Because patients tend not to share this information with doctors, the NIH has developed a kit for physicians to help them discuss CAM therapies with patients. “Most [patients] don’t tell their doctors that they are taking CAM therapies,” says NIH’s Nahin, who is co-author of a 2004 CDC report on CAM use.
“Many CAM and conventional therapies can be used concurrently,” adds Fuoco, “but there are some indications for which you would not want to use them concurrently, so knowing everything a patient is on is helpful.”
To encourage owner disclosure, veterinarians should ask specific questions and avoid being judgmental, even if they don’t endorse the use of CAM therapies, experts say. “I think some people have received negative feedback or been judged in a negative way for some of the treatments they are using. Whether that feedback was from family, friends or a doctor, they don’t tend to offer this information,” Bannink says. “It is important to ask about therapies specifically and in a lot of different ways to make owners feel comfortable with you. They need to understand that it is important for you to know this information so you can give them the best medical advice for their pet.
“I start by asking, ‘What are you giving your pets? Are you giving any vitamins? Are you giving any supplements? Are you giving herbal treatments? How about homeopathic remedies?’ Sometimes just using the CAM terms will help draw them out because they will think you are not judging them,” Bannink says. “They have to understand that my job first and foremost is to serve them and their pet in the best way that I can, and it is harder for me to do that if I don’t have all the information that I need about the treatments the pet is currently receiving. I also need to know whether owners feel the treatments are working.”
Probing questions are important, agrees Fuoco, because many clients do not consider CAM therapies and dietary supplements when asked about what “medications” the animal is receiving. “A lot of people don’t consider supplements as medication or a treatment option. We have to be specific in our history taking. If we ask specific questions, this will be helpful in getting clients to understand what we are looking for themto talk about,” she says.
Once a veterinarian discovers all that the owner is giving to the pet, he or she is obligated to advise the owner about that practice, especially if it is dangerous to the animal—many people believe that a product is safe if it is labeled “all natural,” experts say. As the pet’s doctor, a veterinarian has the right and responsibility to give owners his or her opinion about the animal’s treatments.
“That is part of the patient– provider discussion. There is not a right or wrong way,” says Nahin about discussions between physicians and patients or veterinarians and pet owners. “Doctors use their best judgment to decide what is right for the patient, and the patient [or pet owner] uses his or her best judgment to decide whether to listen to the doctor or not.”
If veterinarians choose to include CAM in their practices, they should seek good training or hire an associate who is certified. The certification programs for acupuncture and chiropractic adjustment are quite rigorous and include 150 hours of study, an internship, writing a peer-reviewed case report and passing a written examination. Accredited institutes and several veterinary schools are offering these programs to licensed veterinarians.
“No veterinarian should be doing CAM therapies without receiving the appropriate training in the specific area of interest,” says Gene F. Giggleman, DVM, dean of academic affairs, professor in the department of anatomical science at the Parker College of Chiropractic in Dallas. Giggleman also is president of the American Veterinary Chiropractic Association.
Even a veterinarian who does not want to become CAM certified should become familiar with CAM modalities and get to know good practitioners to whom they can refer patients because clients will ask about these modalities.
“I think they should try to find someone in their area who is a veterinarian and who is trained in these treatment methods,” says Donato. “Then they can refer patients to a veterinarian who has experience and specializes in these areas. Otherwise, clients will see their own people.”
Next to certification and education, veterinarians should find out the CAM practitioner’s practice philosophy and make sure it agrees with the referring or hiring veterinarian’s philosophy.
“There are CAM practitioners who will only use these methods and will not use conventional medicine but that closes the door to what conventional medicine can offer,” Donato says.
Fuoco agrees: “You both have to be on the same page as far as what is expected of each other. If one does not want to use Western medicine and another thinks it is absolutely necessary, they probably are not going to work well together,” she says.
The experts suggest that anyone who is interested in referring or hiring a veterinarian should talk to CAM providers, as well as their conventional medicine colleagues, to find people who are on the same page. Bannink also suggests that a veterinarian who is just starting down this path pick one or two modalities and spend time learning about them, rather than trying to learn about all of them. “There are so many different facets, it is best to pick one or two that can fit with what you want to do and learn a lot about them,” Bannink suggests.
Make sure that the CAM practitioner makes no guarantees. Just as in conventional medicine, no one knows exactly when or how an individual patient will respond to a treatment. Don’t trust a CAM provider who guarantees results in x number of treatments, Donato says.
“I am honest with clients about the pros and cons of using a certain modality. I can’t tell them how many treatments will fix a dog — 80% show improvement, and it might take about five treatments to do that. I can’tmake false statements or guarantees. There are legal implications. I have clients sign a written waiver saying that there are no guarantees about the results.
“This is still veterinary medicine and I am a veterinarian, so I am liable for what I do,” Donato says. vF
For more information:
Lana SE, Kogan LR, Crump KA, et al.
The use of complementary and alternative therapies
in dogs and cats with cancer. JAAHA 2006;
42:361-365.
Barnes PM, Bloom B, Nahin R. CDC National
Health Statistics Report #12. Complementary
and Alternative Medicine Use Among Adults
and Children: United States, 2007; Dec. 10, 2008.