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10 Articles in Volume 17, Issue #8
A Fresh Look at Opioid Antagonists in Chronic Pain Management
Addressing Chronic Pain in the United States Armed Forces
Are biosimilars as effective as their biologic counterparts?
Integrative Pain Care: When and How to Prescribe?
Lady Gaga, Fame, and Fibromyalgia
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients.
Must-Have Devices for Your Pain Practice
Obsessive-Compulsive Disorder & Chronic Pain
Theory of Motivated Information Management and Coping With Death
United Nations Says Untreated Pain Is “Inhumane and Cruel”

Integrative Pain Care: When and How to Prescribe?

In this Q&A, Robert Alan Bonakdar, MD, director of pain management at Scripps Center for Integrative Medicine in San Diego, California, discusses proven alternative pain management techniques for pain conditions including the lower back, migraines, and osteoarthritis.

The practice of integrative pain management is designed to enhance current treatment models by incorporating a range of nonpharmacological modalities, from acupuncture and massage to mindfulness and yoga, into the routine care of pain patients with the goal of lessening pain and improving function and quality of life. Practical Pain Management spoke with Robert Alan Bonakdar, MD, director of pain management at the Scripps Center for Integrative Medicine in San Diego, California, about which integrative pain practices have shown the greatest efficacy in evidence-based studies for a variety of conditions, specifically chronic low back pain, neuropathic pain, postsurgical pain, osteoarthritis, headache, and fibromyalgia.

Integrative pain therapy modelAn integrative pain therapy model.

What integrative practices for pain offer the greatest efficacy in evidence-based studies?

Research on integrative pain care has evolved at a rapid pace over the past five to 10 years. We have seen a number of influential studies published on yoga, acupuncture, and mindfulness-based stress reduction (MBSR) that have added to our knowledge of effective nonpharmacologic treatments for pain, including massage and Tai-chi. The American College of Physicians’ clinical practice guideline outlines which of these integrative therapies are strongly recommended as initial treatment for chronic low back pain (see Table 1).1

Noninvasive treatments for chronic low back painNoninvasive treatments for chronic low back pain.

For neuropathic pain, the research on acupuncture, especially electroacupuncture, has been impressive, showing improvement in nerve conduction in several studies.2-4 Research also is emerging on the role of cannabinoids in reducing neuropathic pain.5,6

For postsurgical pain, a recent meta-analysis of randomized clinical trials (RCTs) presented moderate-certainty evidence that acupuncture and electrical stimulation significantly reduced and delayed opioid consumption after total knee arthroplasty.7 Given the new mandate from the Joint Commission on Accreditation of Healthcare Organizations for the use of nonpharmacological approaches enhance in-patient pain assessment and management, I believe there will be an accelerated effort to incorporate these options into pain practices.8

Findings from the 18-month Intensive Diet and Exercise for Arthritis (IDEA) trial that showed a supervised diet and exercise program had a significantly greater effect on improving pain and function in knee arthritis than exercise alone.9 It is clear that for osteoarthritis, the role of diet and exercise is indispensable.

Although the value of nutritional supplementation has been confusing because of the sheer number of options on the market, use of the following medical-grade supplements have demonstrated efficacy in clinical trials:

  • Chondroitin: Chondroitin sulfate 800 mg/day was as effective as celecoxib and superior to placebo (P = 0.001) in a prospective RCT of 604 patients with symptomatic knee osteoarthritis.10
  • Turmeric: A meta-analysis of RCTs supported the efficacy of turmeric extract (approximately 1,000 mg/day of curcumin) in the treatment of arthritis. Trials with turmeric/curcumin showed a significant reduction in pain visual analogue score (PVAS) in three studies (mean difference vs placebo: -2.04; P < 0.00001), decreased Western Ontario and McMaster Universities Osteoarthritis Index in 4 studies (mean difference vs placebo: -15.36; P = 0.009), and no significant mean difference in PVAS between turmeric/curcumin and pain medicine in five studies.11

One of the most underutilized
evidence-based tools for management of migraine disorders, including chronic daily headache, and fibromyalgia is biofeedback. This approach appears beneficial in reducing pain amplification by training patients to modulate autonomic dysfunction, including sympathetic overdrive.12-14

Additionally, a number of nutrients—based on correcting a deficiency, providing mitochondrial support, or reducing oxidative stress—appear to improve headache and fibromyalgia pain:

  • Acetyl L-carnitine: This nutrient helps with the conversion of fatty acids into energy. In a RCT comparison of acetyl L-carnitine (1,500 mg/day) to duloxetine (60 mg/day), the nutrient showed positive (nonsignificant) effects on fibromyalgia pain and a significant improvement in depression (P < 0.001) and overall clinical improvement (P < 0.001).15
  • Coenzyme Q10 (CoQ10): Patients with fibromyalgia typically have significantly depressed CoQ10 levels, which is involved in energy production, compared to controls.16 CoQ10 supplementation at 300 mg/day has been shown to restore biochemical parameters and significantly reduce fibromyalgia impact based on the Fibromyalgia Impact Questionnaire, pain level, and related headache (P < 0.001 for all comparisons).16
  • Melatonin: Individuals who took 3 mg of melatonin at bedtime significantly reduced headache frequency compared with placebo (P = 0.009), and it appeared as effective as amitriptyline 25 mg (P = 0.19) but with improved tolerability. Responder rates (>50% reduction in headache frequency) were significantly greater among those taking melatonin than amitriptyline (54.4% vs. 39.1%; P < 0.05).17

Data on these research studies and how to incorporate integrative medicine into pain practices will be featured at the October 2017 Academy of Integrative Pain Management conference (see Resources).

Integrative pain management resourcesIntegrative pain management resources.

Are there cases in which integrative medicine has produced marked improvement?

One of my patients presented with severe neuropathy and had failed (or was not able to tolerate) multiple medications, including anticonvulsants. She was struggling with daily activities and becoming increasingly disabled. In evaluating this patient, we discovered several metabolic/inflammatory issues, including hypovitaminosis D, low carnitine, and low testosterone, as well as elevated C-reactive protein. In addition to prescribing vitamin and hormone supplementation, we initiated electroacupuncture and referred the patient to our dietitian to address her diet, which was pro-inflammatory. After about three months, this patient reported significant improvement in pain, functional ability, and serum markers.

Another great example worth sharing concerns the use of low-dose naltrexone in the setting of fibromyalgia. Based on pilot studies at Stanford, many of our patients have demonstrated remarkable improvements in pain and related symptoms, including fatigue, with naltrexone treatment.18-20

Why have integrative modalities not been more widely embraced for pain?

The greatest barrier to wider use of integrated therapies can be attributed by far to a lack of insurance coverage. We, as clinicians, have a desire and indeed an obligation to follow the latest evidence in providing the best treatment to our patients with pain conditions. Unfortunately, I do not see a similar standard for insurers.

Even as evidence of clinical efficacy for treatments such as MBSR are cost-effective, most insurers are still using outdated policies to deny reimbursement for these therapies. Given the time pressures, clinicians are too busy to fight every one of these denials, and so I hope that there will be higher-level interventions that will help clinicians incorporate evidenced-based guidelines for nonpharmacological care of pain into everyday practice.

Another major barrier is education. The average pain clinician tries to stay current with changes in conventional medical care, including approval of new medications and procedures. With the added need to follow advances in integrative therapies and other areas (eg, dietary interventions) that are not covered sufficiently in medical training, efforts to stay updated this area of research can be daunting.

However, I believe this education barrier can be managed. There are a number of points-of-care resources and conferences that can help clinicians gain familiarity with integrative practices (see Resources). The physicians who embrace with this area of pain management find satisfaction when discussing the options of integrative therapies with patients. This expansion of options (and the prospect of hope that goes with it) for both patients and providers can go a long way in improving the clinic visit. This education also can help clinicians find therapies to help with their own wellness and burnout prevention.

How do patients view integrative therapies?

The two greatest barriers in this realm are the expectation of seeing a quick result coupled with a passive mentality that is common in our current pain treatment system. When I describe to patients that the effects of integrative therapies are cumulative, and may require six or more treatments to feel any benefit—that duration can be a turnoff.

Similarly, it can be challenging for patients to enter into therapies such as biofeedback, mindfulness, or other mind-body training that requires a certain level of daily, active participation. Despite these challenges, I have found in most of my interactions that education on why this approach can provide more sustained long-term benefit helps most patients adopt these approaches.

When might integrative modalities be considered appropriate for pain patients?

Incorporation of integrative modalities into a pain practice will be driven by an individual physician’s interests and resources. For example, I had an interest in offering acupuncture and mindfulness training to my patients, but I was less interested in therapies such as hypnosis and manipulation, even though the evidence regarding these modalities is favorable. I developed the expertise for the therapies I was committed to in-office, and then slowly created resource networks for the other therapies so I could comfortably refer my patients and ease their access to treatments we both agreed were worth trying.

Similarly, physicians can incorporate integrative therapies into their practice by either training themselves or bringing in licensed practitioners. Beyond that, integrative medicine networks can be built in the same way that networks for referrals to physical therapy and other specialists are developed. Building these networks is challenging; however, office staff can be enlisted to garner patient feedback as well as provide patient surveys to gather input on satisfaction with integrative services throughout the community. Base on patient feedback at follow-up visits as well as gauging the level of communication from the integrative health practitioners can be helpful in fine-tuning the local resource network.

What integrative approaches can help prevent burnout in physicians caring for pain patients?

Mindfulness and MBSR have a great potential in this area. A number of studies have examined how physicians and nurses can use these therapies to stay resilient in the wake of an ever-changing and more challenging medical environment.21 What is most interesting is that clinician mindfulness also appears to be correlated with better patient-centered communication and more satisfied patients.22

Are there important studies in integrative pain care worth mentioning?

Several studies point to improved outcomes in pain care through adjunctive use of integrative therapies. Notably, a meta-analysis of more than 20 studies found that different integrative therapies in combination with conventional medical care were more effective than select single therapies alone for treating low back pain.23

Another important recent study found that MBSR in the setting of chronic low back pain had a high probability of being cost-effective compared with usual care, and in fact may reduce total healthcare costs.24 These benefits are likely related to improved coping strategies and mindfulness. In addition, cognitive behavioral therapy also had a high probability of being cost-effective in this study.

I look forward to seeing more studies like these published in the future to help validate why we should be discussing and investing in integrative therapies for our patients.

Do you anticipate new research with promising results for any particular pain condition?

Actually, I am looking forward to results from the Academic Consortium for Integrative Medicine & Health’s year-long initiative to disseminate evidence-informed information and resources on the nonpharmacologic treatment of pain, including postoperative pain. Findings should be available by the end of this year, as well as presented at the consortium’s International Congress in May 2018.

In addition, I am working on a project with the Thought Leadership Foundation (http://thoughtfoundation.org), which includes transitional members of the Samueli Institute’s research team (following the institute’s closing), to develop a summary paper on the evidence of dietary supplements in the setting of musculoskeletal pain. This research is expected by the end of the year and should be helpful for answering clinical questions in this area.

What led to your pursuit of integrative pain care?

I had the great fortune of doing a Richter international fellowship prior to attending medical school, during which time I became fascinated with the Eastern approach to medicine while traveling to Southeast Asia to observe and study meditation, Tai-chi, and acupuncture. It was eye-opening to witness another approach to healthcare that, in many cases, coexisted closely with high-tech, Western approaches without an apparent turf battle. This broadened approach, which sought out the best tool for healing no matter its origin, created a paradigm that I have tried to emulate in my own practice. Although the setting is very different, we see chronic pain patients who deserve the widest menu of options to help them heal and recover.

—Interview by Kristin Della Volpe

Continue Reading:
United Nations Says Untreated Pain Is “Inhumane and Cruel”

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