The NIH National Center for Complementary and Integrative Health (NCCIH) released its draft strategic plan 2016-2021 for public comment in early spring of 2016. The Integrative Health Policy Consortium (IHPC) provided input to strengthen their resolve to investigate mind-body interventions and educate the American public.
- Advance fundamental Science and Methods Development: Advance understanding of basic biological mechanisms of action of natural products, including prebiotics and probiotics; advance understanding of the mechanisms through which mind and body approaches affect health, resiliency, and well-being; and develop new and improved research methods and tools for conducting rigorous studies of complementary health approaches and their integration into health care.
- Improve Care for Hard-to-Manage Symptoms: Develop and improve complementary health approaches and integrative treatment strategies for managing symptoms such as pain, anxiety, and depression; and conduct studies in "real world" clinical settings to test the safety and efficacy of complementary health approaches, including their integration into health care.
- Foster Health Promotion and Disease Prevention: Investigate mechanisms of action of complementary and integrative health approaches in health resilience and practices that improve health and prevent disease; study complementary health approaches to promote health and wellness across the lifespan in diverse populations; explore research opportunities to study and assess the safety and efficacy of complementary health approaches in nonclinical settings such as community and employer-based wellness programs.
- Enhance the Complementary and Integrative Health Research Workforce: Support research training and career development opportunities to increase the number and quality of scientists trained to conduct rigorous, cutting-edge research on complementary and integrative health practices; foster interdisciplinary collaborations and partnerships.
- Disseminate Objective Evidence-based Information on Complementary and Integrative Health Interventions: Disseminate evidence-based information on complementary and integrative health approaches; and develop methods and approaches to enhance public understanding of basic scientific concepts and biomedical research. (For greater detail, go to https://nccih.nih.gov/about/strategic-plans/2016).
In May 2015, a year prior to the release of their new draft plan, IHPC made recommendations in response to their Request for Information to improve upon their plan from 2011-2015, emphasizing increased research grants to CAM accredited colleges. The NCCIH responded with objective four which offers training grants for those Complementary and Integrative Health (CIH) professionals who would like to pursue advanced degrees. They did not, however, increase funding of research to this date.
The NCCIH also listened to our impassioned request to focus more on "health" as we commented on their Strategic Aim three (Increase understanding of "Real-World" Patterns and Outcomes of CAM use and Its Integration Into Health Care and Health Promotion). IHPC wrote, "Poor health status, in mind, body and spirit, is financially draining our country and there is no sign that this trajectory is changing or even slowing. To begin with, a Strategic Plan that reflects "health" would revise and expand upon 2011-15 Strategic Aim #3. We believe this could best be done by increasing the ways in which NCCIH works with other funders of health-oriented projects such as State Departments of Health, the Patient Centered Outcomes Research Institute (PCORI), and other public health agencies."
In this article, I will present a summary of our response to each of the NCCIH major objectives in their 2016-2021 strategic plan. (To access the complete response, please go to www.IHPC.org/NCCIH.Strategic.Plan).
Objective 1
Your reference to mechanistic research in the discussion of objective 1 misses the spirit of holistic health. Rather than focus on the molecular action of a particular intervention, we recommend you focus on real-world outcomes. Comparative effectiveness research is a much more appropriate investigational method to evaluate complementary and integrative health approaches, with the results being applied directly to health policy and clinical guidelines. With that said, we understand the value of investigating the mechanisms of a particular intervention – if completely understood, we can then combine it with other interventions synergizing the therapeutic impact. For example, if acupuncture increases the ability of the brain to bind to endogenous opioids, then using acupuncture in conjunction with exogenous opioids may provide more effective pain therapy, and perhaps allow for lower drug doses.
Objective 2
This objective laudably targets conditions that have a large public health impact, and for which the majority of patients seek complementary and integrative health approaches. As well, the decision to conduct pragmatic studies demonstrates a willingness to grapple with the complexities of how patients seek out and integrate their own care at the point of actual delivery. Under "Imaging and Neurotechnologies" you mention that these technologies may "provide an improved means of measuring and understanding the neurologic circuits that underlie symptoms." We recognize the common mistake of the allopathic mindset of focusing on treating symptoms rather than evaluating and eliminating the root cause. Managing symptoms does not promote health and well-being.
We support NCCIH's strategy of continuing to fund preliminary studies to refine treatment interventions and research methods in order to conduct definitive clinical trials. In this regard we urge NCCIH to find as many ways as possible to support multidisciplinary teams of investigators, including scientists and clinicians from complementary and integrative medicine disciplines to help best describe and apply the clinical practice nuances that arise in their actual clinical practices; and which may be related to significant treatment effects. As we have previously commented, there is a strong need to fund clinical research that studies real-world clinical practice. We appreciate the increased emphasis on real-world CIH use as stated under Objective 2 in the context of pain, anxiety, and depression.
IHPC's perspective comes from representing patients and practitioners using complementary health approaches in the real world. Most of the complementary and integrative health delivered in the United States and received by Americans takes place in the small practices of CIH-trained clinicians who have little, if any, interface with academic research institutions. While this is not convenient to your researcher teams, it doesn't diminish the importance of these clinics as the real-world laboratory in which health and healing occur daily. Support of practice-based research networks, community-based participatory research, IT-supported pragmatic trials, and observational studies would all be appropriate ways to study these real-world settings.
NCCIH should not, however, ignore the inconvenient fact that many complementary and integrative approaches are not yet available in the great majority of mainstream health delivery systems. For example, Doctors of Chiropractic are only minimally represented in the VHA and DoD systems, and have virtually no visible presence in patient-centered medical homes and accountable care organizations. The same is true for other so-called complementary licensed disciplines. Consequently, additional challenges will need to be surmounted to provide fair scientific tests of how these approaches can appropriately benefit "real world" patients in "real world" settings. In order to meet this strategic goal, NCCIH will need to become immersed in policy matters that have traditionally kept these non-medical disciplines generally limited to small individual practices. Providing incentives to health delivery organizations to include complementary and integrative approaches will be necessary.
Objective 3
IHPC strongly supports the inclusion of Objective 3 as part of your strategic plan. While the language identifies complementary health approaches, we hope it also examines the role of complementary health practitioners as agents of change. We also recognize the importance of health and well-being within the hands of the individual. Research into this area will support access to information by the individual to make informed decisions about their lifestyle choices, health behaviors, and self-care. Research and surveys indicate that individuals have already made choices and subjectively experienced positive health effects. The focus of NCCIH in this area shows respect for the capability of people to recognize the effectiveness of complementary health approaches and to take control and ownership of their wellness, as well as disease prevention.
While resiliency is the chosen outcome for NCCIH research, we suggest that a systems approach be included as well. This is substantiated by the NCCIH observation in the Strategic Plan that complementary health approaches are used more often for wellness goals than for treating a specific illness. Wellness is the result of complex, interactional processes and needs to be approached from a "whole person" view. Most CIH practices reflect this view and require non-traditional research methodologies that preserve the integrity of the discipline.
We are very excited that NCCIH has included health and wellness strategies that focus on reaching diverse and traditionally underserved and vulnerable populations. A paradigm shift away from disease management towards wellness and health promotion in non-clinical settings is critical for reaching these populations. Programs emphasizing complementary health approaches to health and wellness are perfect for delivery in non-clinical settings as well as clinical settings. It is important to bring health and wellness messages and affordable programs to people where they spend their time; at work, in faith communities, at culture center activities, etc. We support enhancing programs to reach people where they are, both physically and philosophically.
Objective 4
We applaud the return of a strategic priority addressing the importance of developing research capacity and investment in our future investigators. We appreciate the specific consideration of clinician-scientists with CIH degrees in the Workforce Development Working Group Report. We hope this prioritization will be paralleled with a higher proportion of clinician-scientists on review panels so that the efforts to enhance this domain of the workforce isn't thwarted by review emphasizing PhD basic science.
Objective 5
We wholeheartedly support this objective in theory. However, NCCIH produced a total of thirty-five press releases between 2012 and 2016; none of which covered the effectiveness of acupuncture, massage therapy, naturopathic medicine, homeopathy, or chiropractic care. We strongly advocate you include this information in future press releases. Hopefully, your education strategy will begin with a review of the information (and mis-information) on NCCIH's website. We hope that the "presentation of evidence-base and safety and effectiveness information on complementary health interventions" is balanced with common sense context such that consumers are not discouraged from experiencing supplements and therapies that are inherently safe and beneficial. For example, the risks and harms of mindfulness are so small and the growing evidence base is so substantial that everyone should be encouraged to adopt mind-body techniques and NOT wait for further evidence.
IHPC and the Integrative Health community hope that the NCCIH took our comments to heart, and will shift their research paradigm from mechanistic and symptom-centric to holistic, with a greater focus on promoting health and well-being. We hopefully anticipate future NCCIH press releases and public education to address and present the scientific evidence-base for the primary CIH professions of AOM, Chiropractic, Naturopathic Medicine, Homeopathy, Nutrition, Massage Therapy and Midwifery. They're not off to an impressive start. The NCCIH produced five press releases in the past six months, none of which relate to CIH professions.
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