Complementary and alternative medicine (CAM) is defined by the National Center for Complementary and Alternative Medicine (NCCAM) as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” (1). CAM is defined by the Cochrane collaboration as “a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period” (2). Several therapies once considered “alternative,” such as acupuncture, yoga, and meditative techniques for stress reduction, have become integrated into mainstream medical practice as clinical effectiveness for specific illnesses has been validated by an increasing number of well-designed clinical trials.

The number of adults in the United States using CAM therapies increased from 33.8% in 1990 to 42.1% in 1997 (3). In 2007 the Centers for Disease Control and Prevention’s National Center for Health Statistics estimated that 40% of Americans had used CAM therapies in the past 12 months; of these therapies 17.7% were nonvitamin, nonmineral natural products and 12.5% were instruction and ongoing classes involving the deep breathing exercises inherent in yoga and meditation. Furthermore, at least 34 billion was spent out of pocket on all CAM therapies combined, an estimated 11% of total out-of-pocket health care expenditures, equivalent to 1.5% of total health care expenditures in the United States (4). Worldwide, nearly half of adults living in industrialized countries and a higher percentage of those living in developing countries have used at least one therapy classified as complementary or alternative (5). A large national survey by Astin concluded that people use CAM therapies “not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life” (6).

Among American adolescents surveyed between 1998 and 2007, the prevalence of CAM use ranged from 54% in a metropolitan New York county (7) to 70% of homeless youth in Seattle (8) to 68% in a Midwestern ambulatory care clinic (9). Adolescent patients often seek out CAM therapies for acute and chronic conditions in an effort to self-treat and exert more control and autonomy by choosing therapeutic practices that do not require prescriptions or physician referrals (7). They erroneously believe that “natural” means safe, and they use multiple CAM modalities simultaneously and in conjunction with prescription medications (such as oral contraceptives and antidepressants) and over-the-counter analgesics. Most adolescents do not inform their providers about the CAM therapies they are using unless they are asked specifically, and even then, full disclosure is variable.

In this chapter, several herbs and dietary supplements will be discussed in the context of the clinical conditions in which they are used; these include urinary tract infections (UTIs), dysmenorrhea and premenstrual syndrome (PMS), eating disorders, depression and anxiety, and stress reduction. Evidence-based indications for acupuncture, massage therapy, yoga, and meditation in treating these and other clinical conditions will be presented. A complete review of all CAM modalities is beyond the scope of this chapter; consequently, several modalities, including chiropractic, homeopathy, and energy healing, will not be discussed. Resources for additional clinician and patient information will be provided and suggestions for responsible integration of several beneficial therapies will be proposed.

Plants have been cultivated and utilized for medicinal purposes throughout recorded history. Many of our current medications were initially derived from plants, including aspirin, morphine, Taxol, and several alkylating agents used in chemotherapy. In 2007, Americans spent an estimated $14.8 billion on herbs and dietary supplements, the equivalent of a third of their total out-of-pocket prescription drug costs (4). Most of these products are not standardized, the recommended dosages are variable, and some herbal products, particularly those promoted for weight loss and imported packaged traditional Chinese and Indian Ayurvedic herbal mixtures, may be contaminated with pesticides or heavy metals or adulterated with other biologically active chemicals (10,11). At this time, herbal products and dietary supplements sold in the United States are unregulated, although growing concerns of inadvertent overdoses, dangerous undeclared herbal and pharmaceutical ingredients, drug–herb interactions, and the variability in product quality have prompted policymakers to consider new regulations to protect consumers. When recommended herbal remedies are prepared by trained herbalists and experienced practitioners of Chinese traditional medicine and Indian Ayurvedic medicine using certified, standardized ingredients, the likelihood of quality, safety, and efficacy increases, although well-qualified practitioners can be hard to find and expensive, and their standards of practice may vary.

Adolescents get their information about herbal remedies and dietary and performance-enhancing supplements from their friends, family members, coaches, salespeople in health food stores, and magazines, or directly from the Internet. Most packaged herbal products can be ordered via the Internet or obtained at health food stores and pharmacies without a prescription. Therefore, it is imperative that clinicians ask patients
specifically about their use of herbs, vitamins and supplements, teas, and special diets as part of their standard medical history and preoperative questionnaire.

Several popular herbs are now known to affect surgical and postoperative care. For example, garlic and ginseng inhibit platelet aggregation, gingko inhibits platelet-activating factor, and kava and valerian prolong the sedative effect of anesthesia; these should be discontinued at least 7 days before surgery (12). Other herbs, such as St. John’s wort, affect the serum drug levels of medications metabolized through the cytochrome P450 enzymes and should be discontinued 5 days before surgery and during treatment with cyclosporine, warfarin, steroids, oral contraceptives, digoxin, and protease inhibitors (12,13). Many herbs may also interact with analgesic medications and affect the metabolism and efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids.

When clinicians know what their patients are using they can easily access the most recent data about the safety, efficacy, clinical indications, and known herb–drug interactions of thousands of herbs and supplements by consulting the Web sites and references listed in Table 31-1.

Cranberry (Vaccinium macrocarpon) has long been recommended by herbalists for the prevention of urinary tract infections (UTIs). The active ingredient is now known to be proanthocyanidin, which interferes with the adhesion of gram-negative bacteria uropathogens to the bladder epithelium (14). A case-controlled study of sexually active college students showed that regular consumption of cranberry juice was associated with a 50% reduction in the odds of first-time UTI (15), and in another small study of women with recurrent UTIs the same women had significantly fewer UTIs during an interval when they took 400 mg of cranberry concentrate daily compared to no therapy (16). A 2008 Cochrane Database review of 10 studies concluded that cranberry juice may decrease the number of symptomatic UTIs over a year, especially in women with recurrent UTIs, although it is unclear if juice, tablets, capsules, or dried cranberries provide equivalent effectiveness (17). Cranberry juice is safe and does not adversely affect vaginal bacterial flora or increase the risk of calculi (18). Cranberry does not protect against infection with gram-positive bacteria and has not been shown to be helpful in preventing infections in children and adolescents with neurogenic bladder (19).

As antibiotic resistance increases and compliance with antibiotic therapy is variable, patients and medical practitioners seek safe, preventive strategies. Cranberry juice (unsweetened) consumed as 200 mL to 250 mL two to three times per day or 250 mg cranberry extract tablets (greater than 1:30 parts concentrated juice) twice a day are safe and effective (20), and these products can be recommended to adolescent girls with recurrent UTIs and to sexually active young women. Cranberry products are not effective as monotherapy for established UTIs and they should not be used as such.

Probiotics, which are exogenous bacteria and microorganisms similar to the bacteria living in the human intestinal tract, may be helpful in preventing UTIs, and they have been shown to reduce gastrointestinal infections and diminish the digestive difficulties that often follow treatment with antibiotics (21). Usually probiotics are strains of Lactobacillus and Bifidobacterium that are found in a variety of fermented foods, dairy and soy products, and strain-specific dietary supplements in the form of powders, tablets, and capsules. Probiotic supplements are thought to be safe, although there are case reports of subsequent systemic infections with these bacteria in immunocompromised adults and children with indwelling central venous catheters and short-gut syndrome.

An extensive review of randomized controlled trials (RCTs) of CAM therapies in reproductive-age women was published in 2003 by Fugh-Berman and Kronenberg (22). Herbs that are used to treat menstrual irregularities and/or symptoms of premenstrual syndrome (PMS) in adult and perimenopausal women have not been adequately studied in adolescents, and the safety of long-term use of these herbal products is not currently known. Three popular botanical products, Dong Quai (Angelica sinensis), evening primrose oil, and chaste tree berry (Vitex agnus-castus), are widely marketed remedies and they may be used by adolescents seeking relief from menstrual discomfort and PMS symptoms.

Dong Quai (A. sinensis) is one of several ingredients used in traditional Chinese medicine to create a “female tonic” for menstrual symptoms. Clinical data about its effectiveness as monotherapy for PMS and dysmenorrhea are inconclusive, although one study found that it was “no more efficacious than placebo in relieving menopausal symptoms, and does not alter estrogen levels” (23). However, a 2008 Cochrane Review of 39 RCTs involving 3475 women concluded that “Chinese herbal medicine resulted in significant improvements in pain relief, overall symptoms, and the use of additional medication after three months of follow up compared to commonly used Chinese herbal health products,” although poor methodologic quality of many of the included studies limits these conclusions (24). Dong Quai contains coumarins, which potentiate the effects of prescription anticoagulants and have been reported to cause bleeding (12), and photosensitivity and photodermatitis reactions have also been reported.

Evening primrose oil (EPO), which contains linoleic acid, the prostaglandin E¹

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