Chronic Pain: Why Do We Treat the Whole Person Last, When Good Evidence Says We Should Do It First?

February 2020 Issue

  1. Jenna Walters, MD Assistant Professor of Anesthesiology and Pain Medicine; Associate Chronic Pain Fellowship Director; Chronic Pain Resident Rotation Director, Vanderbilt University Medical Center Co-author
  2. Priyanka Ghosh, MD Interventional Pain Fellow, Weill Cornell Medicine Co-author


The National Institute of Health (NIH) estimated that in 2016, approximately 20% of U.S. adults suffered from chronic pain.[1] Chronic pain is the number one cause of long-term disability in the United States and costs our country an estimated $635 billion each year in direct and indirect costs.[2],[3] As state and national legislation is enacted to combat the opioid epidemic, patients continue to experience chronic pain and are undergoing rapid forced opioid tapers with limited alternative options for pain control. National overdose deaths continue to rise with a twofold increase in the last decade.[4] Numerous studies outline the risks of long-term opioids for chronic, nonmalignant pain, but what is the alternative?[5–7]


“The goal is to treat the whole patient, not just their disease, while empowering patients to live their best life despite chronic pain.”


As patients search for a new way forward, the interest in complementary and alternative medicine has surged in the United States. According to NIH, in 2012 approximately 54% of Americans suffered from a musculoskeletal pain disorder, and 40% of them used complementary and alternative medicine.[8] In light of the opioid epidemic and the call for more options to treat chronic pain, several commercial insurance companies have adopted policies covering alternative modalities such as acupuncture. As interest increases, what do we tell our patients about these therapies?

Acupuncture

A recent review of complementary medicine in the United States found acupuncture to be effective for both pain and function in patients with chronic low back and knee pain.[9] A systematic review by Dimitrova et al also highlighted the benefits of acupuncture in the treatment of painful peripheral neuropathy.[10] Interestingly, the study also showed improvements in both sensory and motor nerve conduction. Xu et al performed a systematic review concluding that acupuncture had a significantly higher effective rate compared to medication for chronic migraines.[11] Finally, the American College of Physicians currently recommends acupuncture for acute, subacute, and chronic low back pain.[12]

Mind-Body Techniques

Mindfulness-based stress reduction has similar results for low back pain with improved pain scores and functionality at 26 and 52 weeks when compared to usual care.[13] It has also been shown to improve mood and catastrophizing, which frequently coexist in patients that experience chronic pain.[14] Multiple randomized controlled trials have highlighted the benefits of mindfulness and meditative awareness for patients who suffer from fibromyalgia, a disease with few treatment options but frequently associated with debilitating symptoms and loss of functionality.[15],[16] Several studies evaluating cognitive-behavioral therapy for fibromyalgia have supported the theory that it affects neuroplasticity and alter brain connectivity.[17],[18]

Physical practices such as yoga and tai chi combine the benefits of a meditative practice with movement. Several systematic reviews have provided evidence that yoga can improve both pain and function for patients with chronic low back pain.[19],[20] A randomized controlled trial performed in veterans demonstrated similar results with improvement in both disability and pain.[21] Tai chi has been studied extensively for chronic pain related to osteoarthritis and has moderate to strong evidence to support the improvement of pain and function.[22],[23] For patients with fibromyalgia, yoga and tai chi may not only improve pain but also quality of life and pain acceptance.[24],[25] Patients with chronic pain frequently suffer from fear avoidance behavior, and mind-body modalities can help break the vicious cycle of pain, anxiety, and fear in relation to movement.

Integrative Programs

Several institutions have used this evidence to support the development of pain rehabilitation or functional restoration programs. The Mayo Clinic in Rochester, MN, created the first such program in 1974. These centers combine alternative modalities with physical therapy, psychological intervention, and education to reduce pain, improve function, decrease opioid burden, and ultimately help patients live better. A systematic review found that multidisciplinary rehabilitation can reduce pain and disability while simultaneously increasing the likelihood of return to work.[26] Unfortunately, patients are typically referred to such programs when they have failed all other modalities. Why are we reserving this type of collaborative therapy as the last option? Instead, it should be the model for how we treat all patients with chronic pain.

The Department of Veterans Affairs has recently made an investment in this treatment paradigm by developing the Whole Health Initiative that uses evidence-based, integrative pain care. The program includes a team of family practitioners, interventionalists, physical and occupational therapists, health coaches, and psychologists that use multimodal medication management, procedural interventions, physical activity, behavioral modification, acupuncture, mindfulness, meditation, biofeedback, yoga, tai chi, and other alternative therapies to treat chronic, nonmalignant pain without high-dose opioids. The goal is to treat the whole patient, not just their disease, while empowering patients to live their best life despite chronic pain. As we battle not only the opioid epidemic, but the financial and emotional impact of chronic pain, this collaborative and integrative model provides the framework for the future of chronic pain treatment—a way forward for our patients.

References

  1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001–1006. https://doi.org/10.15585/mmwr.mm6736a2
  2. National Institute on Drug Abuse website. https://www.drugabuse.gov/related-topics/pain. Updated May 12, 2017. Accessed December 27, 2019.
  3. Gaskin DJ, Richard P. The economic costs of pain in the United States. In: Institute of Medicine Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academic Press; 2011. https://www.ncbi.nlm.nih.gov/books/NBK92521
  4. Overdose death rates. National Institute on Drug Abuse website. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Updated January 2019. Accessed December 27, 2019.
  5. Veiga DR, Monteiro-Soares M, Mendonca L, et al. Effectiveness of opioids for chronic noncancer pain: a two-year multicenter, prospective cohort study with propensity score matching. J Pain. 2019;20(6):706–715. https://doi.org/10.1016/j.jpain.2018.12.007
  6. Krebs EE, Gravely A, Noorbaloochi S. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA. 2018;319(9):872–882. https://doi.org/10.1001/jama.2018.0899
  7. Da Costa BR, Nuesch E, Kasteler R, et al. Oral or transdermal opioids for osteoarthritis of the knee or hip. Cochrane Syst Rev. 2014;9:CD003115. https://doi.org/10.1002/14651858.CD003115.pub4
  8. Clarke TC, Nahin RL, Barnes PM, Stussman BJ. Use of complementary health approaches for musculoskeletal pain disorders among adults: United States 2012. Natl Health Stat Report. 2016;98:1–12.
  9. Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc. 2016;91(9):1292–1306. https://doi.org/10.1016/j.mayocp.2016.06.007
  10. Dimitrova A, Murchison C, Oken B. Acupuncture for the treatment of peripheral neuropathy: a systematic review and meta-analysis. J Altern Complement Med. 2017;23(3):164–179. https://doi.org/10.1089/acm.2016.0155
  11. Xu J, Zhang FQ, Pei J, Ji J. Acupuncture for migraine without aura: a systematic review and meta-analysis. J Integr Med. 2018;16(5):312– 321. https://doi.org/10.1016/j.joim.2018.06.002
  12. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530. https://doi.org/10.7326/M16-2367
  13. Cherkin DC, Anderson ML, Sherman KJ, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315(12):1240–1249. https://doi.org/10.1001/jama.2016.2323
  14. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11:CD007407. https://doi.org/10.1002/14651858.CD007407.pub3
  15. Cash E, Salmon P, Weissbecker I, et al. Mindfulness meditation alleviate fibromyalgia symptoms in women: results of a randomized clinical trial. Ann Behav Med. 2015;49(3):319–330. https://doi.org/10.1007/s12160-014-9665-0
  16. Van Gordon W, Shonin E, Dunn TJ, et al. Meditation awareness training for the treatment of fibromyalgia syndrome: a randomized controlled trial. Br J Health Psychol. 2017;22(1):186–206. https://doi.org/10.1111/bjhp.12224
  17. Lazaridou A, Kim J, Cahalan CM, et al. Effects of cognitive behavioral therapy (cbt) on brain connectivity supporting catastrophizing in fibromyalgia. Clin J Pain. 2017;33(3):215–221. https://doi.org/10.1097/AJP.0000000000000422
  18. Shpaner M, Kelly C, Lieberman G, et al. Unlearning chronic pain: a randomized controlled trial to investigate changes in intrinsic brain connectivity following cognitive behavioral therapy. Neuroimage Clin. 2014;5:365–376. https://doi.org/10.1016/j.nicl.2014.07.008
  19. Cramer H, Lauche R, Haller H, Dobos G. A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013;29(5):450– 460. https://doi.org/10.1097/AJP.0b013e31825e1492
  20. Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;1:CD010671. https://doi.org/10.1002/14651858.CD010671.pub2
  21. Groessl EJ, Liu L, Chang DG, et al. Yoga for military veterans with chronic low back pain: a randomized clinical trial. Am J Prev Med. 2017. https://doi.org/10.1016/j.amepre.2017.05.019
  22. Hall A, Copsey B, Richmond H, et al. Effectiveness of tai chi for chronic musculoskeletal pain conditions: updated systematic review and meta-analysis. Phys Ther. 2017;97(2):227–238. https://doi.org/10.2522/ptj.20160246
  23. Peng P. Tai chi and chronic pain. Reg Anesth Pain Med. 2012;37(4):372–382. https://doi.org/10.1097/AAP.0b013e31824f6629
  24. Carson JW, Carson KM, Jones KD, et al. A pilot randomized controlled trial of the yoga of awareness program in the management of fibromyalgia. Pain. 2010;151(2):530–539. https://doi.org/10.1016/j.pain.2010.08.020
  25. Hall AM, Maher CG, Lam P, Ferreira M, Latimer J. Tai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial. Arthritis Care Res. 2011;63(11):1576–1583. https://doi.org/10.1002/acr.20594
  26. Marin, TJ. Multidisciplinary treatment at the early stages of low back pain. Cochrane Database Syst Rev. 2017;6:CD002193. https://doi.org/10.1002/14651858.CD002193.pub2

 

Tags: complementary, alternative medicine, acupunture, mindfulness, integrative