Who Benefits from Integrative Pain Therapy?

In light of increasing concerns about a reliance on pharmacotherapy for chronic noncancer pain conditions, there has been renewed emphasis on integrative — multidisciplinary and multimodal — pain management approaches focusing on biopsychosocial models. A pair of recently-reported observational studies examined outcomes of integrative pain management programs, finding that they are not beneficial for all patients and are highly dependent on patient characteristics and treatment components.

Study A: Multidisciplinary Treatment of Chronic Widespread Pain (CWP)

Research exploring the effectiveness of multidisciplinary approaches for the treatment of chronic widespread pain (CWP) has been limited, largely due to considerable heterogeneity among patients. Therefore, a research team from Amsterdam, The Netherlands, headed by Aleid de Rooij conducted an observational trial to identify predictors of integrative treatment outcomes in patients with CWP [de Rooij et al. 2013]

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Studies Examine Nondrug Therapies for Neck Pain

Up to half of all persons can expect to experience at least some neck pain in their lifetime. Pharmacotherapy for neck pain is generally only palliative in nature and evidence for the effectiveness of nondrug therapies has been limited. Therefore, neck pain has become a major health burden in most societies worldwide. Three recent studies report on the efficacy of nondrug approaches for managing several types of neck pain, finding favorable outcomes of yoga and fear-avoidance training, while disparaging spinal manipulative therapy.

Study 1: Reducing Fear To Help Improve Whiplash Pain

Writing in the journal PAIN®, researchers at the University of Washington, Seattle, note that between 10% and 42% of people who experience a whiplash-associated disorder (WAD) develop chronic neck pain and may experience other symptoms, such as depression and anxiety [Robinson et al. 2013]. Yet, the majority of patients with WAD initially have neck injuries of lesser severity; namely, grade I (neck symptoms, but no physical signs) or grade II (neck symptoms plus some musculoskeletal signs, such as decreased range of motion or point tenderness).

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Can Antibiotics Cure Chronic Back Pain?

Considerable excitement was recently generated by newly-reported research finding that a significant percentage of patients with chronic lower-back pain could be helped by a 100-day course of antibiotic therapy. While this was hailed as a major medical breakthrough, potentially sparing millions of patients from suffering and major back surgery, some caution seems warranted until this approach is more adequately tested and validated.

Pain specialists have suspected that infections might be involved in certain back pain conditions, but these cases were thought to be exceptional. That thinking has been overturned by scientists at the University of Southern Denmark who found that a third of select chronic lower-back pain cases may be associated with bacterial infection. “This [discovery] will not help people with normal back pain, those with acute or sub-acute pain,” said Hanne Albert, who led the Danish research team, “only those with chronic lower back pain, but it returns those patients to a form of normality they had never expected.”

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Ear Acupressure for Chronic Back Pain?

Auricular point acupressure (APA) is a CAM (complementary and alternative medicine) therapy related to ear acupuncture. Instead of needles, APA uses small seeds or pellets taped to the ear at specific places to stimulate effects elsewhere in the body for treating illness and pain. A small study found that APA was beneficial in relieving chronic low-back pain; however, whether or not this effect was genuine and either APA or ear acupuncture itself are valid therapies for pain conditions are debatable from science-based medicine perspectives.

This study of APA was from an American research team led by Chao Hsing Yeh at the University of Pittsburgh School of Nursing [Yeh et al. 2013]. According to background information in the study report published in Evidence-Based Complementary and Alternative Medicine, customary acupuncture has shown some promising effects for low-back pain, but it is limited by (1) a lack of compelling evidence in high-quality clinical trials, (2) the need for patients to visit an acupuncturist frequently, and (3) associated costs that are often not covered by insurance. Therefore, the researchers believe that APA may offer an attractive solution for treating chronic lower-back pain.

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Reflexology: Implausible Therapy for Pain?

As a form of complementary and alternative medicine (CAM), reflexology has gained popularity in the treatment of various conditions, including those relating to pain. Foot reflexology in particular, as a special type of massage therapy applying principles of Traditional Chinese Medicine, has generated much interest, and a newly reported study examined its effects on pain threshold and tolerance. Although outcomes were reportedly favorable, this and other research on foot reflexology does not appear to provide convincing evidence that it is an effective and durable treatment for any type of pain-related condition. Could this be an example of “Fairy Tale Science”?

Reflexologists propose that a system of reflex areas, or energy zones, reflect an image map of every part, gland, organ, and system of the body on the feet, and specialized foot massage techniques can produce physical changes in the body. An aligned hypothesis posits that meridians, which are essential landmarks for acupuncture throughout the body, converge at the ears, hands, and feet where they can be selectively stimulated by various techniques to produce desired effects that redress imbalances in “energy” that cause illness and pain.

Foot reflexology involves pressure applied to the feet using specific thumb, finger, and hand techniques without the use of oil or lotion. It allegedly dates back to ancient Egypt, but was introduced more recently into Western societies during the early 20th Century. The use of reflexology has increased considerably during the last decade and claims have been made for its use in treating such disorders as infertility, anxiety, depression, and pain.

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May 2013 – Pain Product Announcements & Warnings

Featured Items: lubiprostone (Amitiza) approved for treating opioid-induced constipation; controlled-release oxycodone HCl (OxyContin) abuse-deterrent labeling approved; generic versions of Suboxone (buprenorphine/naloxone) receive FDA approvals. — All brand names are trademarks of their respective manufacturers. Compiled by Winnie Dawson, MA, RN, BSN.

Lubiprostone (Amitiza®) – FDA Approved for Opioid-Induced Constipation
Takeda Pharmaceuticals and Sucampo Pharmaceuticals announced an April 2013 U.S. Food and Drug Administration approval of Amitiza for opioid-induced constipation. Amitiza had already been approved in 2006 to treat adult chronic idiopathic constipation and in 2008 for irritable bowel syndrome with constipation in adult women. The supplemental NDA received a priority review because lubiprostone is the first oral treatment for opioid-induced constipation.

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Manipulative Therapy for Back Pain Revisited

Both acute and chronic lower-back pain (LBP) are exceedingly common, costly, and a significant cause of short- and long-term disability. These conditions are responsible for more than 20 million ambulatory medical care visits in the United States each year, and lifetime prevalence has been estimated to be as high as 84%. In a great many cases, patients seek spinal manipulative therapy (SMT) for their LBP; however, the effectiveness of this approach remains controversial and largely unsupported by high-quality evidence. Three recently reported studies of SMT, performed by either chiropractors or osteopathic physicians, raise further confusion and doubts about the prudence of recommending SMT for persons with nonspecific low-back pain of any duration.

1. Adding Chiropractic to Standard Medical Care for Acute LBP

In the first study, Christine M. Goertz, DC, PhD — vice chancellor for research and health policy at Palmer College of Chiropractic, Davenport, Iowa — and colleagues conducted a naturalistic, prospective, randomized study comparing changes in pain levels and physical functioning in response to standard medical care (SMC) versus SMC plus chiropractic manipulative therapy (CMT) for the treatment of low-back pain (LBP) [Goertz et al. 2013]. Subjects were active-duty U.S. military personnel ages 18 to 35 years, 86% males, with acute LBP of less than 4-weeks duration.

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AMA Opposes PROP Opioid-Label-Change Petition

Ever since last summer, 2012, when Physicians for Responsible Opioid Prescribing (PROP) submitted their petition to the U.S. Food and Drug Administration (FDA) requesting changes to the labeling of opioid analgesic products, there has been a passionate debate raging among those favoring and those opposing the changes. Most professionals seem to believe such actions have no valid scientific justification and would ultimately increase patient suffering — including, most recently, the American Medical Association (AMA).

Founded in 1847, the AMA promotes scientific advancement, improved public health, and strong physician-patient relationships. Empowered by physicians from 185 state and medical societies, the AMA gives voice to the vast majority of physicians in the United States. On April 9, 2013, James L. Madara, MD, AMA Executive Vice President and CEO, submitted a letter to the government’s PROP petition docket, which was addressed to Margaret A. Hamburg, MD, FDA Commissioner. Since such submissions are considered to be in the public domain, we reprint this very notable letter here in its entirety.

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Opioid Dose Alone May Not Influence Overdose Risk

There has been much concern about the safety of long-term opioid analgesics, with some studies reporting unexpectedly high rates of overdoses and deaths as doses are increased. Now, however, preliminary data suggest a contrary perspective in the ongoing debate; that is, higher-dose opioid prescribing may not be a primary influence on overdose.

In an abstract to be presented at the 32nd Annual Scientific Meeting of the American Pain Society in New Orleans, Louisiana, May 8-12, 2013, lead author Paul Coplan and colleagues observe that several prior studies have noted up to an 11-fold increased risk of opioid-analgesic overdose among patients with pain prescribed ≥120 mg versus ≤30 mg daily morphine-equivalent dosage [Coplan et al. 2013]. However, those earlier studies were potentially biased by at least two influences:

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Do Mindfulness Techniques Aid Chronic Pain?

Mindfulness-based interventions (MBIs) emphasizing nonjudgmental attitudes toward present-moment experiences have been widely used to help patients with chronic pain. Although changing or controlling pain is not always an explicit aim of MBIs, a recently reported review of research studies suggests that mindfulness practices may lead to favorable changes in pain tolerance and intensity ratings. However, the evidence in this regard seems neither robust nor highly convincing.

According to background information in the research review article by Keren Reiner, MA, MSc and associates — from the Department of Psychology, Ben Gurion University of the Negev, Beer Sheva, Israel — mindfulness emphasizes a form of detachment whereby thoughts, perceptions, and emotions occupying awareness at the present moment are self-observed without judgment and without attempts to change or control them [Reiner et al. 2013]. Much of the past research has assessed effects on global distress, physical functionality, and quality of life; whereas, benefits of MBI for modulating pain itself have been less studied.

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Warnings Ignored. Now Smack is Back, Big Time!

As previous UPDATES articles warned, there has been a growing resurgence of “smack” (ie, heroin) raging across the United States, due largely to restrictions on pain reliever prescribing and abuse-deterrent formulations of those drugs. According to a recent report in USA Today, heroin is spreading like a cancer into even the most upscale suburban areas throughout the country.

The report by Donna Leinwand Leger [here] in the April 15, 2013 edition of the newspaper notes that heroin was once an urban problem that is now finding a new home in affluent suburbs and small towns throughout America. Fueling the revitalized tsunami of addiction, overdose, and deaths is the fact that opioid medication prescribing is being more closely scrutinized and regulated, and newer formulations of those analgesics deter abuse. So, drug abusers and addicts are turning to more dangerous heroin, which also feeds crime wherever it appears.

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Addiction Fears Trump Pain Relief in Poll

A new national public opinion poll finds that Americans appear to be more concerned about pain-reliever abuse and addiction than chronic pain itself. In fact, slightly more than half of respondents think that healthcare providers should have set limits on the amount of pain medication they can prescribe. Yet, there are many contradictory and confusing aspects of this poll that need careful consideration.

The poll on “Chronic Pain and Drug Addiction” [PDF available here] was conducted online in March 2013 by Zogby Analytics for the Alexandria, VA-based advocacy coalition, Research!America. The survey had a total sample size of 1,016 respondents, with a theoretical sampling error of ±3.1%. According to background information in an accompanying news release [here], chronic pain conditions affect about 100 million U.S. adults at a cost of approximately $600 billion annually in direct medical treatment costs and lost productivity.

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