Integrative Pain Management

Ian J. Koebner, PhD, MSc, MAOM

Anthony DiGirolamo, DO

FAST FACTS

Complementary medicine combines nonmainstream medical practices with conventional medical practice.
Integrative health involves the intentional and coordinated use of complementary medicine.
One of the most common reasons patients seek out complementary medicine is for pain.
Several complementary and integrative health approaches to pain management are safe and effective.

INTRODUCTION

Although chronic pain is widely understood as a complex biopsychosocial phenomenon,¹^,²^,³^,⁴ the degree to which pain is successfully attenuated by physiological, psychological, and/or social interventions is variable. Unfortunately, usual care for some chronic pain conditions increasingly relies on diagnostic tests and treatment options that have not been well validated in terms of safety or effectiveness⁵ and abuse of opioid pain medications has become a major public health concern in the United States.⁶ Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined.⁶ For every unintentional overdose death related to an opioid analgesic, 9 persons are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics.⁶ Faced with an epidemic of chronic pain,⁷ usual care that can be ineffective or unsafe,⁵^,⁸ and a health care workforce unprepared to meet these challenges,⁷^,⁹ many individuals turn toward complementary or integrative health approaches to address their pain.

Complementary health approaches encompass a wide range of procedures by licensed practitioners (e.g., acupuncturists, chiropractors, and massage therapists), self-care approaches (e.g., meditation and movement-based practices), and natural products (e.g., dietary supplements such as herbal medicines).¹⁰ The National Institutes of Health’s (NIH) lead agency for scientific research on complementary and integrative health approaches, the National Center for Complementary and Integrative Health (NCCIH), defines complementary medicine as the use of a nonmainstream practice used together with conventional medicine.¹¹ Conventional medicine refers to allopathic medicine as taught in medical schools, which generally engages the patient around a problem or a disease, focusing on disease management over health promotion.¹¹ Alternative medicine, the use of a nonmainstream practice in place of conventional medicine, is rare.¹¹ Although a number of definitions and constructs exist for integrative health,¹² they all involve in part the intentional and coordinated use of complementary medicine. The National Academy of Medicine describes integrative medicine as “orienting the health care process to create a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for the achievement of optimal health throughout the life span.”¹³

About 30% to 40% of US adults use complementary approaches to health in a given year,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸ most commonly for painful health conditions.¹⁴^,¹⁵^,¹⁷^,¹⁸^,¹⁹ The National Health Interview Survey of 2007, for example, demonstrated that approximately 14.3 million adults used a complementary health approach for back pain, 5.0 million adults used these approaches for neck pain, and 3.1 million adults used these approaches for arthritis.¹⁰^,¹⁴ The high utilization of complementary health approaches has created
a significant cash market for these services and products. In 2007, individuals spent $8.5 billion in out-of-pocket payments on complementary health approaches to manage back pain, $3.6 billion to manage neck pain, and $2.3 billion to manage arthritis.¹⁰^,¹⁹ By comparison, individuals used complementary health approaches much less often and spent significantly less out of pocket for other chronic diseases such as depression (1.0 million adults/$1.1 billion), hypertension (0.8 million adults/$0.7 billion), diabetes (0.7 million adults/$0.3 billion), or cancer (0.4 million adults/$0.2 billion).¹⁰^,¹⁴^,¹⁹

The widespread use of complementary health approaches for pain has led to numerous mechanistic and clinical trials to assess their safety and effectiveness. For example, an evidence-based evaluation of complementary health approaches for pain management published by the NIH-NCCIH¹⁰ explored some of the most frequently used complementary health approaches used to treat common pain conditions seen by primary care providers within the United States.¹⁰ In 2017, the American College of Physicians (ACP) established guidelines for the noninvasive treatment of low back pain that included recommendations for several complementary therapies.²⁰ Over the past 5 years, the Ottawa Panel has established several guidelines supporting the use of complementary therapies to manage neck, back, and knee pain.²¹^,²²^,²³ The results of these studies are outlined in Tables 26-1, 26-2, 26-3, 26-4. A comprehensive review of all complementary health approaches for all painful conditions is beyond the scope of this chapter. Instead, details on the effectiveness and safety of several widely used complementary health approaches for common pain conditions seen in the primary care setting are presented. Biologically based therapies, including supplements, are not discussed; although individual studies have variable results, a recent systematic review of select supplements commonly used in the treatment of pain revealed insufficient evidence to support their use.¹⁰

ACUPUNCTURE

Although the origin of acupuncture is a subject of debate, the practice was already codified by the first century BC in the Huang Di Nei Jing (The Yellow Emperor’s Internal Classic).²⁴ In 1976, the New England School of Acupuncture became the first American college of acupuncture and oriental medicine. There are approximately 65 accredited or candidacy status schools with the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), and 42 states and the District of Columbia regulate acupuncture.²⁵ All candidates for a state license are required to pass the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) examination except for California, which administers its own comprehensive examination.²⁶ ACAOM requires a 3-year/27-month, 1905-hour, 105-semester-credits program to receive the Master of Acupuncture degree and a 4-year/36-month, 2625-hour, 146-semester-credits program to qualify for the Master of Acupuncture and Oriental Medicine degree, which includes training in Chinese herbal medicine.²⁶

TABLE 26-1 Summary of ACP Guidelines for the Use of Select Complementary Health Approaches for Low Back Pain

TYPE OF CAM	ACUTE TO SUBACUTE LOW BACK PAIN	CHRONIC LOW BACK PAIN
Acupuncture	Strong recommendation	Strong recommendation
Spinal manipulation	Strong recommendation	Strong recommendation
Massage	Strong recommendation	Insufficient evidence
Meditation^a	Insufficient evidence	Strong recommendation
Tai chi	Insufficient evidence	Strong recommendation
Yoga	Insufficient evidence	Strong recommendation
Adapted from Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. 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.
^aMindfulness-based stress reduction.
ACP, American College of Physicians; CAM, complementary and alternative medicine.

Acupuncture has been shown to provide significant relief of both acute and chronic low back pain and is currently recommended by ACP guidelines.²⁰ There is also a body of evidence to suggest that acupuncture may provide significant improvements in knee pain in the setting of osteoarthritis.¹⁰ Several studies have shown that acupuncture may be beneficial in reducing impact scores of chronic daily headaches¹⁰^,²⁷ and long-term reduction in migraine recurrence.²⁸ Acupuncture may also provide pain relief for patients with fibromyalgia; however, better quality studies are needed.²⁹^,³⁰ There is a moderate level of evidence to suggest acupuncture is beneficial in the treatment of neck pain.³¹ Acupuncture is generally well tolerated with low risk of adverse events; in the above-mentioned studies, adverse events were minimal and included minor pain and/or bruising at the needle site¹⁰ and vasovagal symptoms.²⁹

SPINAL MANIPULATION

Spinal manipulation dates to ancient times and has roots within most cultures of the world. Traditionally referred to as “bone setting,” manipulation of the spine and peripheral joints was described by Hippocrates and has been recorded in a multitude of physician and surgical texts over the millennia.³² For unclear reasons, bone setting fell out of favor within the US medical community in the 19th century.³² It was during this time, however, that the 2 leading professions of spinal manipulation, osteopathic medicine and chiropractic, were born. Currently within the United States, both chiropractors
and osteopathic physicians continue to use spinal manipulation techniques. Within some states, spinal manipulation is also practiced in the fields of physical therapy and naturopathic medicine depending on individual state licensing and scope of practice laws.

TABLE 26-2 Summary of Benefits for the Use of Complementary Health Approaches for Select Pain Conditions

TYPE OF CAM	BACK PAIN	KNEE PAIN (OA)	NECK PAIN	HEADACHES	FIBROMYALGIA
Acupuncture	Beneficial ++	Beneficial ++	Insufficient evidence	Insufficient evidence	Insufficient evidence
Spinal manipulation	Beneficial +	Insufficient evidence	Insufficient evidence	Insufficient evidence	Insufficient evidence
Massage	Beneficial +	Insufficient evidence	Beneficial ++	Insufficient evidence	Insufficient evidence
Relaxation approaches	Insufficient evidence	Insufficient evidence	Insufficient evidence	Beneficial ++	Beneficial +
Tai chi	Insufficient evidence	Beneficial ++	Insufficient evidence	Insufficient evidence	Beneficial +
Yoga	Beneficial ++	Insufficient evidence	Insufficient evidence	Insufficient evidence	Insufficient evidence
Reprinted from 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. Copyright © 2016 Mayo Foundation for Medical Education and Research. With permission.
The above summary may be used as a guide to help the primary care provider identify possible complementary health approaches for their patients with a chronic pain condition.
(++) stronger evidence of benefit; (+) weaker evidence of benefit; CAM, complementary and alternative medicine; OA, osteoarthritis.