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Integrative pain management

May 2014
BY VICTOR S. SIERPINA, MD, ABFP, ABIHM, Director, Medical Student Education Program , WD and Laura Nell Nicholson Family Professor of Integrative Medicine, Professor, Family Medicine, University of Texas Distinguished Teaching Professor

Following up on last month’s sobering MJH theme of addiction, I wish to address the pain management issue through the lens of integrative medicine. Recall the challenge so well presented in the cover articles of that issue by Drs. W. Clay Brown and Mike Leath entitled, “Good Intentions; Unintended Consequences,” and “The Opioid Dilemma: A Catch-22 in Medical Practice?” by Dr. J Lance LaFleur.

The treatment of pain is one of the deepest core values of healthcare professions. To relieve pain in another is almost a reflex borne out of both our humanity and the altruism of the healing arts. This is true whatever form the pain comes in: the skinned knee of a crying child, the grimace of pain in an elderly whose arthritic back limits her movement, the horrific pain of a combat injury, the crush and trauma of a motor vehicle accident, the attentiongetting pain of a myocardial infarction, or the progressive pain of advancing cancer from decaying tissue and bones in a hospice patient.

All of kinds of pain deserves our attention and merits the finest and latest approaches medicine can offer. Therapies can and do include prescription and nonprescription drugs, procedures like surgery, nerve ablations, anesthetic injections, implantable devices and pumps, physical and occupational therapy, and the rest of the arsenal of palliative care medicine.

Acute pain is something we generally know how to manage well. It is chronic pain that gives us the greatest challenges, particularly non-lethal, non-cancer related chronic pain. In this void there be dragons including drug addiction, overdose, depression, hopelessness, disability, even suicide.

As a primary care family physician, I see plenty of this kind of chronic pain. In our UTMB-Health Family Medicine clinics, we have progressively initiated pain and opiate contracts for all non-cancer pain patients to assure compliance with medication levels, employ random drug testing, and utilize the Prescription Access in Texas (P.A.T.) database to monitor if they are obtaining medications from multiple doctors or pharmacies. The P.A.T. website is https:// www.texaspatx.com.

These measures are meant to protect the patient, but also the provider’s liability from the slow, and often not-so-hidden progression of addiction and prescription drug abuse.

To address the well-recognized gap between maximum medication management and untreated chronic pain, the role of integrative medicine has increasingly shown to be effective. One example is use of the mind-body therapies. Relaxation, imagery, biofeedback, hypnosis, meditation, and mindfulness have all been shown to reduce pain and suffering by altering not only neurotransmitters and sympathetic tone, but also by altering perception and beliefs about pain that magnify pain rather than ameliorate it.

A comprehensive book on this topic, entitled Integrative Pain Management, will be published in 2015 by the Weil Integrative Medicine Library. Edited by my friend and colleague Robert Bonakdar who heads Scripps Integrative Medicine Center’s Pain Management program, this promises to be a highly instructive and useful resource for those of us who manage chronic pain. I found out about this upcoming publication when Dr. Bonakdar, who shares my love of Tai Chi, asked me to write the chapter on Tai Chi and osteoarthritis, complete with pictures and video.

At supper recently in a neighborhood Mediterranean restaurant on the California coast, he and I discussed many of the principles of integrative pain management including evolving science supporting them. This includes effects on the vagal nerve pathway, endorphins, inflammatory cytokines, and rewiring of brain pathways that can be affected by modalities from diet to acupuncture.

With his blessing, I am sharing the overall layout and topics of the book to give you some sense of the spectrum of integrative management options for chronic pain. I’ll be sure to provide a full book review for MJH early next year when it is published.

Following the introductory materials by renowned integrative medicine authors such as Andrew Weil and David Rakel, the first section explores the paradigm and context of integrative pain management. Next come chapters on neurological mechanisms underlying pain including central sensitization, neuropathic pain, central pain, contextual mediators of chronic pain, medication management, neuroblockades, and surgical pain treatment.

and considerations leads off with the biopsychosocial context of pain and the importance of getting the full patient story. Unfortunately we may often be tempted to see a patient with chronic pain as an annoyance in our busy day, as a drug seeker, as someone often addicted to pain meds, with a disability consciousness, and as a dependent, overly needy person. While these stereotypes might frequently fit, they often gloss over the deeper issues that may have led to their current poor state of health. They also harden our hearts and thought system with indifference and cynicism rather than fostering care and compassion.

Following the suggestion of a recent journal article, I asked one of my patients with chronic, disabling back pain to write down a short life story. He obliged and brought me to tears as I read of this veteran’s early childhood history of abuse, abandonment, and a severely dysfunctional family. Another patient with deep depression and chronic fibromyalgia as well as recurrent pelvic pain relates a similar story of sexual abuse, abandonment, and maltreatment by her family of origin. With some of the background of such early pain in their formative years, we discover wounds that cannot heal, scars of an earlier era, and hopefully can develop better understanding for what underlies often seemingly insoluble problems.

When routine medical, anesthesiology, or surgical measures fail to help such patients through chronic pain, you may wish to consider referrals to such complementary practitioners as chiropractors, massage therapists, acupuncturists, movement and exercise therapists. Whole systems approaches such as traditional Chinese medicine, naturopathy, Ayurveda, as well as spiritual and energetic practitioners may be of service.

Decreasing inflammation through an antiinflammatory diet and the use of various supplements, omega-3 oils, botanical medicines, and hormones may also be helpful when applied by skilled hands. The mind- body therapies I mentioned above can also be augmented by psychotherapy as well as physical movement therapies such as yoga and Tai Chi in treating chronic pain. These movement methods can help by restoring function, improving conditioning, centering balance and posture, fostering relaxation, and optimizing benefits of deep breathing.

Collaborative approaches in patients with chronic pain may be the perfect opportunity to foster team-based and interdisciplinary care and to work together with multiple health professionals on tough problems. These can include chronic headache, recurrent abdominal or pelvic pain, chronic musculoskeletal and neuropathic pain, fibromyalgia, cancer, myofascial pain syndromes, and other forms of pain.

As difficult as chronic pain can be to manage, to avoid secondary problems such as addiction and substance abuse, we need to expand the range of services offered in our hospitals, clinics, and referral networks to include a full integrative pain management spectrum. This will guarantee that we best serve the needs of some of our most challenging and often most vulnerable patients.