CAM/Nutrition Exam 2 — Study Guide

1 · Introduction to Complementary and Alternative Medicine

1.1 Defining the Landscape IO 1

Conventional healthcare is the system in which healthcare professionals — physicians, physician assistants, nurse practitioners, pharmacists, physical therapists, and nurses — treat symptoms and diseases using drugs, radiation, or surgery. It travels under several other names, all of which mean the same thing: allopathic medicine, biomedicine, mainstream medicine, orthodox medicine, and Western medicine.

Complementary and alternative medicine refers to a broad range of health practices, approaches, and products that are not traditionally part of conventional Western medicine. The single most testable distinction in this lecture is the one between the two halves of that phrase:

Integrative medicine is a patient-centered, whole-person approach that combines conventional medicine with evidence-based complementary therapies. It emphasizes wellness, prevention, and the therapeutic relationship, and uses multiple treatment modalities when appropriate — for example medication plus physical therapy plus yoga or acupuncture.

Functional medicine is also whole-person and patient-centered, but its organizing idea is different: it focuses on the potential underlying contributors to disease, weighing lifestyle, nutrition, environment, genetics, and psychosocial factors. Prevention uses nutrition, exercise, sleep, and smoking cessation; treatment uses dietary change, stress reduction, physical activity, and evidence-based supplements.

Hippocrates, often called the Father of Medicine, anchors the historical end of this material. He is credited with “Let food be thy medicine,” and the original Hippocratic Oath commits the physician to order the best diet for the sick according to judgment and means, and to take care that patients suffer no hurt or damage.

The National Center for Complementary and Integrative Health is the federal government's lead agency for scientific research on complementary and integrative health approaches. It sits within the National Institutes of Health, inside the United States Department of Health and Human Services. It conducts and supports research on the safety, effectiveness, and mechanisms of complementary health practices, and provides evidence-based information for patients and healthcare professionals. Note what it is not: it does not license practitioners, approve products, or accredit training programs.

1.2 Why Patients Choose These Approaches IO 2

The lecture gives six reasons for the popularity of complementary and alternative medicine:

• Perceived as natural and safe
• Desire for greater control over personal health
• Dissatisfaction with conventional treatments or outcomes
• Interest in a more holistic, patient-centered approach
• Easy access to information, products, and services
• Value placed on the time, attention, and therapeutic relationship offered by practitioners

1.3 The Clinician's Role and Patient Counseling IO 6

Many clinicians receive limited formal training in these therapies, which makes a deliberate approach more important rather than less. The lecture asks clinicians to:

• Maintain an open, respectful, and nonjudgmental dialogue
• Routinely ask patients about complementary and alternative use
• Evaluate these therapies using the best available scientific evidence
• Direct patients to reliable sources — the national center, the National Institutes of Health, the Centers for Disease Control and Prevention, and peer-reviewed literature
• Monitor for safety, including herb-drug and supplement-drug interactions

The lecture then gives a checklist of questions to raise with a patient who is considering a therapy. These are high-yield precisely because they are a list:

1.4 The Five Domains IO 3

The teaching framework for this lecture divides complementary and alternative medicine into five domains. Learn them as a set — the exam is far more likely to ask which domain a therapy belongs to than to ask for a definition in isolation.

1.5 Whole Medical Systems IO 3

Whole medical systems are practices built on complete systems of theory and practice that evolved separately from conventional medicine, many of them centuries before it. Each has a defined philosophy and its own explanation of disease, diagnosis, and therapy. The four examples are Ayurveda, homeopathy, naturopathy, and traditional Chinese medicine.

Ayurveda is the traditional medical system of India and one of the world's oldest healing systems, still an important component of healthcare there. The name comes from the Sanskrit ayur (life) and veda (knowledge or science). Health is believed to result from balance among the body's fundamental energies, the doshas; illness is believed to arise when they become imbalanced. Doshas derive from combinations of five elements — space (ether), air, fire, water, and earth — and most people are believed to have one dominant dosha.

After determining the balance of doshas, the practitioner designs an individualized plan using diet, herbs, massage, meditation, yoga, and internal cleansing (therapeutic elimination). Research is limited to studies of individual herbs such as turmeric and ashwagandha rather than of the complete system.

Homeopathy was developed in Germany in the late 1700s. The name comes from the Greek homeo (like) and pathos (disease). It rests on two theories:

Products may be derived from plants (red onion, poison ivy, belladonna), minerals (arsenic), or animals (crushed whole bees). The theory proposes that remedies retain therapeutic properties despite extensive dilution.

Naturopathy is founded on the healing power of nature and the body's inherent capacity for healing. It emphasizes prevention, a healthy lifestyle, and treatment of the whole person, and focuses on finding the cause of disease rather than only treating symptoms. Its therapies include hydrotherapy, dietary counseling, nutritional supplementation, medicinal herbs, acupuncture, physical therapies such as heat and cold, mind-body therapies, and exercise therapy.

Traditional Chinese medicine originated in China and evolved over thousands of years. Common practices include acupuncture, herbal medicine, dietary therapy, massage, tai chi, and qigong. A vital force of life called Qi (pronounced “chee”) is believed to flow along pathways called meridians, sometimes described as an energy highway. Disease is thought to result from disruption or imbalance in the flow of Qi, and health is believed to depend on balance between the opposing and complementary forces of Yin and Yang. Humans are understood as interconnected with nature, and five elements — earth, fire, water, wood, and metal — form the basis of many concepts.

Several practices have been evaluated in clinical studies. Acupuncture and tai chi may improve quality of life and help manage certain pain conditions. Evidence for Chinese herbal products varies by product and condition, and some have been found to contain heavy metals, pesticides, and microorganisms. Herb-drug interactions should be considered when counseling patients.

1.6 Mind-Body Medicine IO 5

Mind-body medicine focuses on the interactions between the brain, mind, body, and behavior and their influence on health. Scientific evidence supports benefits for several of these interventions, and many are now integrated into conventional healthcare — used for chronic pain, anxiety and stress-related disorders, insomnia, headache, and cancer-related symptoms. Behavioral, psychologic, and spiritual techniques are used to reduce symptoms, improve coping, and enhance quality of life.

Objective 5 asks you to define five specific techniques, so they are worth holding side by side:

Monitored functions include heart rate, blood pressure, muscle activity, skin temperature, breathing patterns, and brain activity. Sensors are placed on the body, information is displayed in real time visually or audibly, and patients learn to modify their responses through guided practice. Multiple sessions are typically required. Evidence supports biofeedback as an adjunctive therapy for migraine, tension-type headache, stress-related disorders, and some pelvic floor dysfunctions. The goal is self-regulation without reliance on the monitoring equipment.

Hypnosis deserves special attention because the lecture spends a slide on myths. Clinical hypnotherapy uses guided relaxation, focused attention, and therapeutic suggestion. The exact mechanism is poorly understood, and individuals vary in responsiveness. Indications include acute and chronic pain, anxiety, stress and phobias, irritable bowel syndrome, nausea and vomiting, procedure-related distress, habit disorders, insomnia, and adjunctive support during childbirth.

Meditation may help reduce stress, anxiety, chronic pain, and insomnia, and can improve coping and quality of life in chronic illness. It works by promoting a physiologic relaxation response, increasing awareness of thoughts, emotions, and behaviors, and reducing automatic reactions to stress. The two most commonly studied forms are:

• Transcendental meditation — silently repeating a mantra, traditionally 20 minutes twice daily; studied for stress, anxiety, and cardiovascular health.
• Mindfulness meditation — being intensely aware of what one is sensing and feeling in the moment, without interpretation or judgment; often practiced through mindful breathing.

Relaxation therapy may be combined with meditation, guided imagery, or hypnotherapy. The relaxation response is associated with slower breathing, decreased heart rate, and lower blood pressure. Techniques include progressive muscle relaxation (systematically tensing and relaxing muscle groups to recognize and reduce tension) and guided imagery (for example a beach: the smell of salt water, the sound of waves, the warmth of the sun).

1.7 Biologically Based Practices IO 3

Biologically based practices use naturally occurring substances to promote health or manage disease: botanical medicine, natural products and supplements, chelation therapy, and diet therapies. Benefits and risks vary, and evidence, product quality, and potential drug interactions should be evaluated before use.

Botanical medicine is the use of plants or plant extracts for medicinal purposes, consisting of plant materials, algae, macroscopic fungi, or combinations. Forms include solutions such as tea, powders, tablets, capsules, elixirs, topicals, and injections.

Dietary supplements are among the most commonly used complementary health approaches and are widely available without a prescription. Common products include vitamins, minerals, probiotics, botanicals, and specialty supplements. Patients often use them without discussing them with healthcare professionals, so potential benefits, adverse effects, and drug-supplement interactions must be actively considered.

Chelation therapy works by a defined mechanism: chelating drugs bind with metals and enhance their excretion from the body. Established medical uses include lead poisoning, iron overload, and other heavy metal toxicities. Common environmental exposures are lead (old paint, plumbing), arsenic (well water, rice), and mercury (fish).

Diet therapies are specialized dietary approaches such as Mediterranean, plant-based, and intermittent fasting patterns. They may support prevention and management of chronic disease and are often used to promote overall wellness. Evidence varies by dietary pattern and clinical condition, and nutritional adequacy plus patient-specific factors should be considered before recommending change.

1.8 Manipulative and Body-Based Practices IO 3

These practices focus on the musculoskeletal system and soft tissues — bones, joints, muscles, and connective tissues — using hands-on techniques to improve function, reduce pain, and promote well-being. The lecture lists chiropractic, osteopathic manipulation, cupping, massage, reflexology, and gua sha.

1.9 Energy Therapies IO 3

Energy therapies are based on the belief that biofields — energy fields — influence health and healing. Many traditions describe a vital life force such as Qi thought to flow through the body, and some therapies aim to manipulate these proposed fields to promote healing. Examples are Reiki, therapeutic touch, and acupuncture.

2 · Herbal Medicines and Medical Marijuana

2.1 · Objective d — Supplements, DSHEA, and the FDA IO d

Dietary supplements include herbs, vitamins and minerals, most of them plant-derived, plus hormones such as DHEA, melatonin, insulin and growth hormone. They are the most common alternative therapy in use today, with worldwide sales over $150 billion and more than $50 billion in the United States in 2021. The whole regulatory picture follows from one statute.

The Dietary Supplement Health and Education Act of 1994 (DSHEA) defined dietary supplement and dietary ingredient, and — the single most testable point — regulates herbs as dietary supplements, not as drugs, and does so only after they are already on the market. It required ingredient and nutrition labeling, and granted the FDA authority to establish good manufacturing practice (GMP) regulations, which the lecture notes are not rigorously adhered to.

What people assume	What DSHEA actually provides
The FDA checks purity before sale	No standardized purity or bioavailability guarantees exist
Manufacturers must report harms	No requirement for reporting adverse effects
Supplements are held to drug standards	They are not “drugs”; FDA oversight is much less than for over-the-counter drugs
Health claims are vetted	Drug efficacy claims are prohibited — labels must say claims have “not been evaluated or approved by the Food and Drug Administration”
The FDA polices advertising	False or misleading advertising and adverse events go through the Federal Trade Commission

Sourcing is its own hazard. After the first purchase in a practitioner's office, 1 in 3 patients refills from Amazon or another online retailer — and the FDA estimates 2 of every 3 supplements sold online is a counterfeit. Potency also varies with climate, soil, where the plant was grown, harvested and stored, and batch-to-batch differences, and products may contain heavy metals, unlabeled prescription drugs, or toxic plants.

2.2 · Objective a — Commonly Used Herbal Medicines IO a

Some vocabulary first. A botanical is a substance made from part of a plant — bark, roots or leaves. Herbalism is the study and practice of using plant material for food, medicine and health promotion. An herbalist or herbal practitioner has undergone specific study and supervised practical training to achieve competence in treating patients, and phytotherapy is the term used primarily in Europe for treating and preventing disease with herbal medicines. Preparations include teas and tinctures (both rapidly absorbed; tinctures contain alcohol), capsules, tablets and tea pills.

Herbal medicine is not fringe pharmacology — a great deal of the formulary descends from it: morphine from opium poppy, digitalis (digoxin) from foxglove, reserpine from rauwolfia, aspirin from willow bark, quinidine from the cinchona tree, and the vinca alkaloids from periwinkle.

Supplement	What it is used for
Fish oil / omega-3 (DHA, EPA)	Mild fall in blood pressure and triglycerides, reduced platelet aggregation and inflammation; DHA more for cognition and fetal brain and eye development, EPA more for inflammation and vasodilation
Glucosamine ± chondroitin	Osteoarthritis and joint problems; glucosamine from proteins and shellfish, chondroitin from animal cartilage
Methylsulfonylmethane (MSM)	Mainly osteoarthritis; also gastrointestinal upset, musculoskeletal pain, allergies, immune support
Flaxseed	Hypercholesterolemia, cardioprotection, immune function; contains omega-3 and alpha lipoic acid
Ginseng	Fatigue, sexual dysfunction, stomach disorders, asthma; avoid with caffeine
Chamomile / lavender / lemon balm	Sleeplessness, anxiety, gastrointestinal upset; lemon balm also studied in dementia and Alzheimer disease
Echinacea	Common cold and infection, on the premise it stimulates immunity — may reduce chance of illness but not its length
Peppermint	Digestive disorders, irritable bowel syndrome, colds, headaches; oil topically for aches and itching
Milk thistle (silymarin)	Toxic liver damage, chronic inflammatory liver disease, cirrhosis, chronic hepatitis (especially hepatitis C); antioxidant, anti-inflammatory, antifibrotic
Green tea (EGCG)	Studied for cancer, diabetes and heart disease
Turmeric / curcumin	Anti-inflammatory, anticancer and antioxidant properties in laboratory work; arthritis pain
Coenzyme Q10	Mitochondrial energy production, densest in cardiac tissue; production declines with age
Garlic	Anti-inflammatory, cholesterol lowering, slightly lower blood pressure, slows atherosclerosis
Saw palmetto	Benign prostatic hyperplasia (NIH found no benefit; evidence mixed) and hair loss; a 5-alpha-reductase inhibitor
Capsaicin	Topical pain relief by reducing substance P; thermogenic, raises local circulation

Adaptogens are natural substances that help the body adapt to stress, support metabolic function and restore balance — restoring endocrine hormone balance, modulating immunity, and allowing the body to maintain optimal homeostasis. The 1968 formulation by Brekhman and Dardymov is worth the quote: they have a “normalizing influence on physiology, irrespective of the direction of change from physiological norms caused by the stressor.” Examples include Asian and American ginseng, ashwagandha, holy basil, licorice, reishi, rhodiola and schisandra.

Antioxidant and detox cluster. Alpha lipoic acid recycles coenzyme Q10 and vitamins C and E, chelates mercury, lead and arsenic, and has evidence in type 2 diabetes insulin resistance and neuropathy (600–1,200 mg daily in studies). N-acetylcysteine is a glutathione precursor, antioxidant and mucolytic used for acetaminophen overdose. Glutathione itself is cysteine + glycine + glutamine, with its detox power in the sulfur; roughly half of patients lack GSTM1 function. Ubiquinol (reduced coenzyme Q10) absorbs up to eight times better than ubiquinone (oxidized).

2.3 · Objective b — Adverse Effects and Drug Interactions IO b

“But it's all natural” is the belief this objective exists to dismantle. Supplements can increase bleeding risk, alter the response to anesthesia, and interact with prescription drugs.

Herb / supplement	Interaction that matters
St. John's Wort	CYP3A4 inducer — speeds metabolism and reduces effectiveness of antidepressants, birth control pills, cyclosporine, digoxin, indinavir, irinotecan, phenytoin, phenobarbital and warfarin; may increase photosensitivity
Vitamin K, fish oil, “blood moving” herbs	Increase the anticoagulant effect of warfarin → bleeding
Green tea	Contains small amounts of vitamin K, making warfarin less effective — note this runs opposite to the row above
Vitamins C and E (antioxidants)	May reduce effectiveness of some chemotherapy
Glucosamine	Avoid in shellfish allergy; interacts with NSAIDs, diabetic agents including insulin; caution with potassium supplements and anticoagulants
Flaxseed	Can slow absorption of all medications; anticoagulants, diabetes medications, contraceptives, hormones, antihyperlipidemics
Chamomile	Cyclosporine and warfarin
Peppermint	Iron, cyclosporine, antibiotics and antifungals, seizure medications, antihypertensives; never on the face of infants or young children — inhaled menthol can cause serious effects
Garlic	Thins blood similarly to aspirin; interferes with saquinavir in HIV infection
Milk thistle	May lower blood glucose — caution in diabetes, hypoglycemia, or on glucose-altering drugs
Black cohosh	Discontinue and seek review for liver disorder or symptoms such as abdominal pain, dark urine or jaundice
Evening primrose oil	May increase bleeding on warfarin
Statins (the reverse direction)	Statins and diabetic medications lower coenzyme Q10; one study showed a nearly 40% fall in plasma CoQ10
Multivitamins / multiminerals	One per day; not with milk or antacids; no salt substitutes (potassium); can alter blood pressure medications, diuretics, some antibiotics, NSAIDs, tretinoin and isotretinoin

Do-not-use lists are testable too. Echinacea has a low medication-interaction risk but should be avoided in autoimmune disorder, anxiety or depression, asthma, cancer, migraines and seizures. Lemon balm and MSM have no well-documented interactions — MSM has no identified contraindications, though use caution in sulfa allergy, and bromelain carries a pineapple-allergy caution.

2.4 · Objective c — Asking About Herbs in the History IO c

Patients often do not volunteer herb or high-dose vitamin use. The lecture gives two reasons: they may assume “natural” products are harmless, and they may fear their provider will be skeptical. The provider side is equally blunt — prescriber ignorance about supplements is often not caused by a lack of reliable data but by the practitioner's own reluctance or disapproval about seeking that information out for patients.

Populations needing extra care: avoid herbs in contemplated pregnancy and lactation; dose children with extreme care (doses are weight-based); and watch polypharmacy in the elderly. Be alert for side effects and know when to stop the herb.

The lecture also gives four questions to hand the patient: does the product promise rapid improvement in health or performance? Does it seem too good to be true? Does the manufacturer rest its case on a single study or a series of anecdotes? And who funded the research? That last question generalizes — most herbal studies are low quality, with small samples, flawed statistical design, possibly exaggerated findings, and tested products that may not match what a patient actually buys.

Take-home stance. Do not discount supplements out of personal bias; patients will use them regardless. Facilitate their communication with you, warn about adverse effects, interactions and contraindications, recommend high-quality products rather than the cheapest, and refer to high-quality evidence — “googling can lead you astray.”

2.5 · Objective e — Medical Marijuana, THC and CBD IO e

The endocannabinoid system is two G-protein coupled receptors, CB1 and CB2, plus regulatory enzymes. It modulates pain, seizure threshold, appetite, digestion and mood, and may play a role in intraocular pressure. Phytocannabinoids are found in the flowers of the cannabis plant — more than 100 have been discovered, but only a few are well characterized, mainly delta-9 tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD). Terpenes give smell and may have an effect of their own.

	Δ9-THC	Cannabidiol (CBD)
Receptor action	Partial agonist at both CB1 and CB2, higher affinity for CB1	CB2 agonist (anti-inflammatory); reduces THC psychoactivity by altering CB1 shape
Psychoactivity	Yes — CB1 is in the central nervous system and throughout the brain	Major non-psychotropic cannabinoid
Other effects	—	Anti-anxiety, anti-nausea, anti-arthritic, anti-epileptic, anti-psychotic
Other sites	—	5-HT1A (anxiolytic, antidepressant), desensitizes TRPV1, increases adenosine signaling, GPR55 antagonist, GABA-A
Metabolism note	First-pass metabolism yields 11-hydroxy-THC — longer lasting and more psychoactive than Δ9-THC	—

Where the receptors are. CB1: central nervous system and brain (hence psychoactivity), plus immune cells, gastrointestinal, reproductive, adrenal, heart, lung and bladder tissue. CB2: mainly the immune system.

2.6 · Objective f — Conditions That May Benefit IO f

Florida's qualifying conditions, per the Department of Health Office of Medical Marijuana Use: cancer, epilepsy, glaucoma, HIV/AIDS, post-traumatic stress disorder, amyotrophic lateral sclerosis, Crohn disease, Parkinson disease, multiple sclerosis, conditions of the same kind or class, a terminal condition diagnosed by a physician other than the certifying physician, and chronic nonmalignant pain caused by or originating from a qualifying condition and persisting beyond its usual course.

The evidence is more modest than the list implies. A 2015 meta-analysis found randomised controlled trials for chemotherapy-associated nausea and vomiting, appetite stimulation in HIV/AIDS, chronic pain, spasticity in multiple sclerosis, depression, anxiety, sleep disorder and glaucoma — with most studies showing only modest symptom improvement.

JAMA 2015 candidate criteria — an appropriate candidate has (1) a debilitating condition with randomised-trial data suggesting benefit, (2) multiple failed trials of first- and second-line agents, (3) failed use of an FDA-approved cannabinoid such as dronabinol or nabilone, and (4) no active substance abuse, psychotic disorder, or unstable mood or anxiety disorder. It is not a first-line treatment.

2.7 · Objective g — Delivery Methods IO g

Routes: edibles, nasal spray, oral, suppository, topical cream, inhalation and flower. The two the lecture contrasts directly are the two you should be able to separate cold.

	Oral	Inhalation
Onset	10–30 minutes	60–90 seconds
Duration	6–8 hours	About 2 hours
Best for	Chronic, long-term effect	Breakthrough symptoms
Poor choice in	Malabsorption — try suppository, inhaled or sublingual	Chronic obstructive pulmonary disease, or asthma triggered by inhalants

Product types. High CBD strains are described as universal (AC/DC, Remedy, Pennywise). Among high THC: sativa is uplifting and stimulating, good for daytime (Sour Diesel, Lemon Haze, Maui Wowie); indica is relaxing and good for sleep (Granddaddy Purple, Bubba Kush, Purple Kush); hybrids mix the two (Girl Scout Cookies, Blue Dream, Pineapple Express).

2.8 · Objective h — Pharmacokinetics and Pharmacodynamics IO h

Dosing has no fixed schedule. The principle is low and slow — some recommend 4 mg three times daily and titrate — with good record keeping and follow-up with the primary care provider for other medication titrations. Over 10 mg of THC at once can produce euphoria.

Interaction data are thin, so predictions rest on cytochrome P-450. Use caution with narrow-therapeutic-window drugs, and expect interaction with sympathomimetics, central nervous system depressants and anticholinergics — alcohol, benzodiazepines, selective serotonin reuptake inhibitors and zolpidem.

2.9 · Objective i — Cannabis Adverse Effects and Interactions IO i

The safety profile is described as relatively positive: headache, dry eyes, dry mouth, dizziness, lightheadedness, numbness and cough; serious adverse effects rare; low to moderate dependence potential; and an active dose very far below the lethal dose. The dose-dependent split is testable:

High CBD	High THC
Somnolence, decreased appetite, diarrhea, fatigue; possible effects on hepatic drug metabolism and fertility capacity	Anxiety, cholinergic deficits, immunosuppression; paranoid ideation and psychotic symptoms possible but rare

Contraindications. Absolute — acute psychosis, unstable psychiatric conditions, hypersensitivity to cannabis, safflower oil or other components. Relative — severe cardiovascular, immune, liver or kidney disease. Cannabis can exacerbate arrhythmia, worsen bronchitis and pneumonia, and carries a possible association with myocardial infarction, stroke and peripheral vascular disease. Studies suggest use in young adults raises the risk of developing psychosis in high-risk individuals.

Rimonabant is the cautionary tale: a CB1 blocker approved in Europe in 2006 as an anti-obesity drug and withdrawn in 2009 for depression, anxiety and suicidal ideation. It was never approved in the United States.

Cannabinoid hyperemesis syndrome has major criteria of cyclical nausea and vomiting, a compulsion to bathe in hot water, chronic daily cannabis use for more than three years, and mild abdominal pain; minor criteria are age under 50, morning predominance, normal bowel habits, and negative laboratory, radiographic and endoscopic results. It is refractory to antiemetics and typically needs haloperidol or droperidol, with intravenous fluids and lorazepam helping; stopping cannabis takes weeks because of fat deposits. Three explanations are offered for the hot-water behaviour: disrupted hypothalamic thermoregulation, heat countering CB1 hyperstimulation, and “cutaneous steal” redistributing blood away from the gut.

2.10 · Objective j — Florida Law IO j

Florida's law passed in November 2016. Medical marijuana is approved by the state but still illegal federally, it is a recommendation from a physician, not a prescription, and it is allowed for home use only. Because the FDA banned cannabis for so long, little clinical research exists for many conditions.

Route	Daily dose	70-day supply limit
Edibles	60 mg THC	4,200 mg THC
Inhalation	350 mg THC	24,500 mg THC
Oral	200 mg THC	14,000 mg THC
Sublingual	190 mg THC	13,300 mg THC
Suppository	195 mg THC	13,650 mg THC
Topical	150 mg THC	10,500 mg THC
Smokable flower	2.025 g	2.5 ounces per 35 days

The two numbers to hold. Patients are certified for three 70-day supplies, or six 35-day supplies for smoking only, and the aggregate THC total cannot exceed 350 mg/day or 24,500 mg per 70-day supply for non-smoking routes.

Test yourself — 5 questions

3 · Animal-Assisted Therapy

3.1 · Objective 1 — History IO 1

3.2 · Objective 2 — Benefits IO 2

The benefits divide cleanly by modality, which is the most efficient way to hold them.

3.3 · Objective 3 — Training and Certification IO 3

3.4 · Objective 4 — Which Animals, and Which Legal Category IO 4

This is the highest-yield table in the lecture, because the three categories carry different species limits and completely different legal protections.

Three more Americans with Disabilities Act rules round this out. Only two questions may be asked: is the dog a service animal required because of a disability, and what work is the dog trained to perform. Any breed may be a service dog, and entry cannot be refused on breed alone. And a hospital must generally allow a service animal in the patient's room and anywhere else patients and the public may go — it cannot be excluded on the grounds that staff could provide the same service.

3.5 · Objective 5 — Canine-Assisted Therapies IO 5

3.6 · Objective 6 — Equine-Assisted Therapies IO 6

Why horses at all? They are sentient beings that perceive and feel, and they are prey animals — highly aware of their surroundings, social and herd animals that mirror the emotions of those around them (calm produces calm), establish boundaries, and seek a leader they can trust and who will protect them. They are exquisitely sensitive to how we present ourselves and highly responsive to human body language and nonverbal cues. That sensitivity is the therapeutic instrument.

The lecture names three equine modalities. Keep them apart by asking who is in the arena and what the goal is called.

4 · Acupuncture & Traditional Chinese Medicine

4.1 History IO 1

Acupuncture developed as part of Traditional Chinese Medicine roughly 4,000 years ago. The Yellow Emperor's book of internal medicine (about 200 BC) is the early written source; about 350 points were described by 300 AD, and it spread to Korea, Japan and India between 600 and 900 AD. It was practised in Europe in the 1500s to 1700s, then suppressed by the Ching Dynasty (1644–1911) and the Nationalist Regime (1911–1949).

Scale and licensure: more than 6.5 percent of United States adults have used acupuncture, over 10 million treatments a year, in more than 103 countries. Over 38,000 licensed acupuncturists; licensure differs by state, with 47 of 50 licensing. Florida requires a four-year master's degree, more than 2,700 supervised hours, and the national certification examinations.

4.2 Traditional Chinese Medicine, yin and yang IO 2 · IO 3

Five branches: acupuncture · herbalism · massage or tuina · diet and nutrition · movement (Tai Chi Chuan, Qigong).

It does not reject unexplained illness, does not separate psyche from soma, and does not treat the disease in isolation — it considers the person alongside nature and the social setting.

Five basic constituents: Qi (energy) · Xue (blood) · Jin Ye (body fluids) · Jing (life essence) · Shen (spirit).

4.3 Meridians, organs and elements IO 4 · IO 5

Meridians are the paths through which Qi travels, named after organs. There are six pairs plus two unpaired channels (Du and Ren), carrying 361 points plus extra points, numbered and named to a World Health Organization standard.

“Organ” here is not confined to anatomical structure — it means all the functions ascribed to that organ.

Zang (yin, solid): lung, heart, spleen, kidney, liver, pericardium. Fu (yang, hollow): large intestine, small intestine, stomach, bladder, gallbladder, Sanjiao.

4.4 Syndromes and energy-moving points IO 7

Six exogenous factors: wind (tremors, tics, spasms, headaches) · cold (gastrointestinal, colds) · summer heat (heat stroke) · damp (gastrointestinal, skin, edema) · dryness (lungs, gut, skin) · fire heat (mania, anxiety, skin). Miscellaneous factors: irregular food intake, stress, lack of exercise, traumatic injury, stagnant blood or phlegm.

4.5 Trigger points and mechanism IO 6

A myofascial trigger point is a small area, 3 to 5 millimetres, within a muscle that remains abnormal after injury. It may cause chronic pain and stiffness, can propagate to fibrositis or fibromyalgia, and refers pain in consistent patterns. Trigger points show about 70 percent correspondence with classical acupuncture points, and sit at muscle origins, insertions and motor points.

How it works: local effects · segmental effects and gate control · descending inhibition · central effects, with release of endorphins, serotonin, enkephalins, gamma-aminobutyric acid, norepinephrine and dopamine. Acupuncture also produces prolonged elevation of serotonin and effects on mood, behaviour and the reticular activating system.

4.6 Indications, cautions and adjuncts IO 8

Adjuncts: moxibustion (burning dried mugwort for heat, used since 500 BCE, to move Qi and blood) · cupping (glass cups and a flame creating suction; stationary cups 5–10 minutes, walking/sliding cups moved along a meridian, flying cups rapidly removed and replaced) · ear acupuncture including the NADA protocol for anxiety, depression and substance abuse, used by the military and some emergency departments · Tai Chi, a slow internal martial art that reduces fall risk in older adults and lowers stress, anxiety and blood pressure.

5 · Chiropractic, Massage, Homeopathy, Aromatherapy & Reiki

5.1 Chiropractic medicine IO 1 · IO 2

Chiropractic centres on the diagnosis, treatment and prevention of neuro-musculoskeletal disorders, focusing on the relationship between structure (movements of the spine) and function (coordinated by the nervous system). Chiropractors locate misaligned vertebrae causing nerve pressure, and relieve it by restoring joint alignment and motion.

Founded by Daniel Palmer, Iowa, 1895; 39 states regulated it by 1931; today more than 70,000 licensed chiropractors, 19 accredited programmes, regulated in all states. The degree needs a bachelor's first, then six didactic and four clinical semesters plus national boards parts one to four, taking three and a half to four years.

Diagnostics: history · inspection · posture analysis, stationary and walking · palpation · orthopaedic and neurologic testing · imaging · body scans (thermography, electromyography).

5.2 The adjustment IO 2

A high-velocity, low-amplitude thrust, usually by hand, directed at specific articulations of the spine or extremities. Its purpose is to restore normal movement and resolve the biomechanical, physiological and neurological effects of segmental hypomobility.

All share one goal: restore normal motion and normalise the nervous system. The reasoning chain: loss of normal movement → changes in how tissues are stressed and replenished → chemical changes → predisposition to mechanical failure.

5.3 Safety and evidence IO 1

In 1994 the Agency for Health Care Policy and Research placed spinal manipulation at the top of the clinical options for certain types of back pain; among 23 options for low back pain, spinal manipulation and non-steroidal anti-inflammatory drugs had the most beneficial effect. Patient satisfaction in back pain is greater with chiropractic than with conventional management.

5.4 Massage therapy: history and principles IO 3 · IO 4

Massage comes from Arabic massa (to touch) and Greek massein (to knead). China 3000 BCE (Tui Na) · India 3000 BCE (Ayurvedic) · Egypt 2500 BCE (tomb paintings) · Japan 1000 BCE (Shiatsu). In medieval Europe the Church of Rome discouraged it. Per Ling, a Swedish physician, founded modern Swedish massage in the early 19th century. Licensure needs 500 to 1,000 hours by state, plus the Federation of State Massage Therapy Boards examination.

It is a mechanical modality used to manipulate tissue, promoting local and systemic relaxation, increasing local blood flow, breaking down adhesions and encouraging venous return.

5.5 Techniques compared IO 5

Mediums (lotions, oils, powder, analgesic balms) decrease friction between skin and hand — but may interfere during petrissage and friction massage.

5.6 Effects and benefits IO 6

Light and slow techniques evoke systemic relaxation; fast and deep techniques increase local blood circulation. Research failed to support the old cardiovascular claims: no increase in cardiac output, blood pressure or long-term arterial flow — though massage can lower heart rate, breathing rate and blood pressure when the purpose is relaxation.

• Petrissage decreases neuromuscular excitability, but only during the massage and only in the muscle massaged.
• Deep effleurage and friction improve flexibility; massage may reduce delayed onset muscle soreness about two hours afterwards.
• Pain reduction by easing swelling and spasm, reducing edema, increasing blood flow and waste removal, and activating sensory nerves.
• Skin: increased temperature and sweating, decreased electrical resistance, removal of dead cells.
• Psychological: reduced anxiety, depression and mental stress; increased compliance and confidence in the clinician.

5.7 Homeopathy, aromatherapy and Reiki IO 7

Homeopathy was founded around 1814 by a German physician. Sources are plant substances (more than 60 percent), animal substances, minerals and chemical elements, healthy and diseased tissues, and bacteria and viruses. Remedies are made by maceration, steeping in alcohol to a mother tincture, then serial dilution and potentisation.

The simillimum is the close match between the patient's full physical, mental and emotional picture and a known remedy picture. Most helpful in recurring childhood infections, chronic disease, the grey area between health and overt disease, behavioural problems and drug intolerance; least helpful in anatomical abnormalities needing surgery, end-stage disease, and where obstacles to cure exist. Kleijen's meta-analysis of 107 controlled trials found 77 percent positive, with higher-quality studies more likely to favour homeopathy.

Aromatherapy is the use of essential oils for therapeutic purposes, via massage, inhalation, oral consumption, compresses and baths. Guidelines: keep bottles closed, protect from sun and heat, less is better, dilute with lotion on skin, and know the oil's properties and quality.

Reiki is a Japanese technique from the early 1900s for stress reduction and relaxation that also promotes healing — “laying on hands”, working with an unseen life force energy: low energy means more illness and stress, high energy more happiness and health.