When patients with chronic pain visit Erica Kumala, MD, at the Family Medicine Clinic at Alvernon, they likely won’t leave with an opioid prescription. Rather, the second-year resident in the University of Arizona—Tucson Alvernon Family Medicine Residency program may recommend they try a supplement like magnesium or refer them to a local yoga class as part of their treatment plan.
Kumala is part of a group of medical residents who are receiving specialized training through the University of Arizona Center for Integrative Medicine, which involves instruction in how to care for patients suffering from chronic pain with reductions in or without the use of opioids.
The training can’t come soon enough. As opioid misuse, addiction, and overdose reach historic proportions, medical schools across the country are incorporating training in nonpharmacological treatment options into their curriculums. Major research laboratories are also devoting time and resources to exploring the efficacy of integrative therapies.
“[There is] very broad agreement at this moment in time to address the crisis we face in our country,” says Victoria Maizes, MD, executive director of the University of Arizona Center for Integrative Medicine and chief of the University of Arizona Division of Integrative Medicine. To do that, “we have to train health professionals about all the other ways in which their patients might manage pain differently.”
Helping a nation in pain
An estimated 92 million U.S. adults use prescription opioids for pain, and 11.5 million misuse them, according to the 2015 National Survey on Drug Use and Health.
Those statistics, along with a growing epidemic of overdose deaths due to the use of legal and illegal opioids, has prompted some of the most prominent medical organizations and agencies – including the American College of Physicians and the Centers for Disease Control and Prevention – to support greater use of nonpharmacological therapies for chronic pain, moving away from opioids as a first line of defense.
“We have to train health professionals about all the other ways in which their patients might manage pain differently.”
Victoria Maizes, MD
University of Arizona Center for Integrative Medicine
Indeed, the National Institutes of Health (NIH) last year launched a cross-divisional effort — the Helping to End Addiction Long-term (HEAL) Initiative — that focuses on evidence-based treatments for opioid misuse and addiction, as well as more innovative solutions for pain management. As part of that effort, the National Center for Complementary and Integrative Health (NCCIH), a division of NIH that leads scientific research on health approaches outside the boundaries of conventional medicine, has accelerated its own research into nonpharmacological treatments for chronic pain.
“There is a biological basis to these approaches, and the research done appropriately can uncover these mechanisms,” says David Shurtleff, PhD, deputy director at the NCCIH.
Bolstering the research base
Complementary and integrative therapies have existed in some form or another for thousands of years, although they have yet to be incorporated into mainstream medical care in the United States.
One issue is that the science is mixed on complementary and integrative therapies, with little evidence in some cases and varying degrees of effectiveness among treatments that have been documented in research.
Monday, March 25, 2019
Taking on low back pain
Low back pain is no small matter, with 80% of adults experiencing the affliction at some point in their lives. It’s also bound up in the opioid epidemic, with many people turning to opioids to alleviate their suffering.
“Most people ... are treated with opioids, and that’s certainly not the best way to start with the treatment of chronic low back pain,” says Shurtleff.
As part of the NIH Back Pain Research Consortium (NIH BACPAC), the National Center for Complementary and Integrative Health is focusing on the mind and body mechanisms of back pain and complementary therapies for treatment.
The agency is also collaborating with the Centers for Medicare and Medicaid Services (CMS) on a clinical trial of acupuncture involving older adults in real-world settings.
The NIH BACPAC trial may have important implications for health care, as its success could lead to more insurance coverage for complementary and integrative therapies.
“If that study proves positive, then there’s a path forward for CMS to allow reimbursement for acupuncture for the treatment of lower back pain,” making it a potential “game-changer,” says Shurtleff.
“There still are unanswered questions, and the research base absolutely could be stronger,” says Maizes.
For instance, a 2018 systematic review of comparative evidence from the Agency for Healthcare Research and Quality found most effects of noninvasive, nonpharmacological treatments for several common chronic pain conditions were small, with little evidence on long-term outcomes. Many interventions had low or insufficient evidence. And even within modalities there were differences in effectiveness depending on the type of pain and how long it lasted. However, the review concluded that the “findings provide(d) some support for clinical strategies that focus on use of nonpharmacological therapies for specific chronic pain conditions.”
By contrast, a 2017 narrative review found “strong positive evidence” for acupuncture in treating chronic pain, as well as “positive preliminary evidence” on the effectiveness of yoga, relaxation techniques, tai chi, massage therapy, and spinal manipulation in treating pain. It concluded, “in the current opioid crisis era, many integrative medical therapies can be used as complements to address pain and reduce opioid abuse and addiction-related disease.”
Major research institutions that have been looking at the science for decades are integral to making sense of the evidence base.
“This is where more research from the NIH or NCCIH can be helpful in guiding that clinical practice,” says Shurtleff.
Under the HEAL Initiative, the NCCIH is funding research on the effectiveness of behavioral interventions, such as mindfulness meditation and cognitive behavioral therapy, in helping people with opioid use disorder adhere to medication-assisted treatment, improve outcomes, and reduce relapse.
Giving people the skills to cope with pain long term is an important component of the initiative. Too often, people with opioid addiction haven’t learned to effectively manage their pain, says NCCIH Director Helene Langevin, MD.
“In a way, what we’re trying to do is help people get back to a healthier state in addition to helping them deal with the addiction itself,” she says.
While the HEAL Initiative is just one component of addressing the national public health emergency that links opioid use and chronic pain, it does offer some hope.
“In a way, what we’re trying to do is help people get back to a healthier state in addition to helping them deal with the addiction itself.”
Helene Langevin, MD
National Center for Complementary and Integrative Health
“If there’s one thing that can result from this crisis, it’s a greater awareness that people need to take charge of their health. There are ways and techniques and tools that patients can be taught in order to do that better,” says Langevin.
Academic medicine at the forefront
Since the first meeting of what is now the Academic Consortium for Integrative Medicine and Health in 1999, complementary and integrative medicine (CIM) has had much stronger representation in academic medicine. The consortium now includes more than 70 academic institutions and health systems in the United States, Canada, and Mexico. One of those institutions is the University of California, San Francisco, (UCSF) Osher Center for Integrative Medicine.
Cameron Niven, a first-year medical student at UCSF, was skeptical about CIM before enrolling in a pain management minicourse at the Osher Center. While she had personally experienced success with spinal manipulation for back pain associated with her Crohn's disease, she wasn’t sure other modalities were effective. After taking the course, Niven gained a deeper appreciation of what CIM approaches can offer people in pain.
“It was reflective of the experience that I have had as a patient. That it’s a journey; it’s a process to feeling better with these integrative techniques,” says Niven.
Anand Dhruva, MD, associate director of education at the Osher Center, who taught the minicourse, is excited by the prospect of stronger evidence for certain modalities. “Not only should we be teaching more about these nonpharmacological approaches, but we also need research to go hand in hand with that,” he says.
A gradual embrace
Wider embrace of CIM in the medical field is progressing, albeit slowly.
When it comes to physicians, "We understandably want to go with what's familiar, because the stakes are so high,” says Adam Rindfleisch, MD, director of the University of Wisconsin-Madison Integrative Health Program at the University of Wisconsin School of Medicine and Public Health. “We are talking about people's bodies, mental health, their entire quality of life."
Besides the need for more research into nonconventional therapies, there are also barriers to treatment for patients and providers. One hurdle is getting insurance to cover complementary and integrative therapies, which can be out of reach for some of the most vulnerable populations.
But buoyed by initiatives such as HEAL and growing support from the academic medicine community, CIM could gain greater acceptance. Already, major policy groups support integrative approaches to pain management, Maizes notes.
“It’s not that everybody is prepared to acknowledge that this should be a part of medicine that we practice in the United States, but more and more people are ready for it,” she says.