Chronic Pain: Why Do We Treat the Whole Person Last, When Good Evidence Says We Should Do It First?
The National Institute of Health (NIH) estimated that in 2016, approximately 20% of U.S. adults suffered from chronic pain. 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., 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. 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. 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?
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. A systematic review by Dimitrova et al also highlighted the benefits of acupuncture in the treatment of painful peripheral neuropathy. 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. Finally, the American College of Physicians currently recommends acupuncture for acute, subacute, and chronic low back pain.
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. It has also been shown to improve mood and catastrophizing, which frequently coexist in patients that experience chronic pain. 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., Several studies evaluating cognitive-behavioral therapy for fibromyalgia have supported the theory that it affects neuroplasticity and alter brain connectivity.,
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., A randomized controlled trial performed in veterans demonstrated similar results with improvement in both disability and pain. 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., For patients with fibromyalgia, yoga and tai chi may not only improve pain but also quality of life and pain acceptance., 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.
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. 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.
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- National Institute on Drug Abuse website. https://www.drugabuse.gov/related-topics/pain. Updated May 12, 2017. Accessed December 27, 2019.
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