Friday, December 17, 2010

A Holiday Wish List for Holistic Pain Care

Holiday CandleFor the 78 million adults with chronic pain in the United States alone, freedom from pain is probably at the top of their “wish lists” for the holidays. The range of therapeutic options for achieving this is actually much broader than many patients and healthcare providers may realize. However, most important may be a holistic perspective that puts the patient at the center of the pain management universe and recognizes that pain relief is but one step on a long road to recovery for better physical, mental, emotional, and spiritual health.

For the past several years in these News/Research UPDATES we have reported on the many and varied approaches to pain management that have appeared in the medical press and scientific literature. Until now, however, we have not assembled a complete listing of those. Most of our list entries below may be familiar to readers, while others may spark new ideas for consideration.

To begin, most of the research in the pain management field, as well as training in traditional Western medicine, focuses on 3 broad therapeutic modalities for the management of chronic or intractable pain:
  1. Pharmacotherapy — is usually first-line treatment for acute or chronic pain, as evidenced by the predominance of education and research on this modality across multiple medical disciplines. The catalogue of drugs used for managing pain is far-ranging, including traditional analgesics (non-opioids and opioids), specialized antirheumatic and antimigraine agents, and adjuvant drugs (eg, antidepressant, anticonvulsants, antiarrhythmics, corticosteroids, and many others). Routes of administration are diverse, including topical, oral, parenteral, and others.
  2. Interventional Medicine — is a still-emerging discipline that includes moderately invasive procedures, such as percutaneous administration of drugs in selected regions to spur healing processes (eg, prolotherapy) or the blocking or ablation of targeted nerves, and the application of intrathecal infusion pumps and neurostimulators. More invasively, there are various techniques for the repair of injured vertebrae and intervertebral disks. Newer developments include electrotherapies and radiofrequency (eg, shockwave) therapies, and others.
  3. Surgery — is generally viewed as an option of last resort, depending on the severity and type of injury or anatomic disorder, and is most invasive. Within pain medicine, this is usually the purview of orthopedic and neurologic surgeons, and the range of procedures is extensive.
Those 3 modalities are often effective in helping relieve pain to some extent but may be characterized as passivelydoing something to the patient, rather than requiring more active, ongoing participation of the patient as an integral part of the therapeutic process and long-term recovery. While compliance with a pharmacotherapy regimen or following postsurgical instructions is expected of patients, immediate pain relief is the primary objective and is generally viewed as hinging on success of the drug, intervention, or procedure.

From a holistic perspective, much more is to be expected. We recently became aware of the Bravewell Collaborative [website here], a nonprofit organization founded in 2002 with a focus on integrative medicine that is well-suited for pain management. The organization brings together a community of philanthropists, institutions, organizations, and medical leaders with a philosophy of care that addresses the full range of physical, emotional, mental, social, spiritual, and environmental influences affecting a person’s health. Fundamentally, this is holistic medicine at its core and does the following:
  • Is patient-centered care that focuses on healing the whole person — mind, body, and spirit in the context of community;
  • Educates and empowers patients to be active participants in their own care, and to take responsibility for their own health and wellness;
  • Integrates the best of Western scientific medicine with a broader understanding of the nature of illness, healing, and wellness;
  • Makes use of all appropriate therapeutic approaches and evidenced-based global medical modalities to achieve optimal health and healing;
  • Encourages healing partnerships between providers and patients;
  • Supports the individualization of care; and
  • Creates a culture of wellness.
Most, but not all, modalities included under the integrative banner have been studied as Complementary and Alternative Medicine, or CAM; however, the approach also involves treatments from conventional medicine for which there is evidence of safety and efficacy. The Bravewell organization lists the following 21 therapies as important components of an integrative approach to medicine and also of benefit for persons with chronic pain [in alphabetical order; also see here for explanations]:
> Acupuncture
> Aromatherapy
> Ayurveda Healing
> Biofeedback
> Chiropractic
> Cognitive Behavioral Therapy
> Energy Medicine (eg, healing touch, Reiki)
> Herbal Medicine (eg, botanical medicine, phytomedicine)
> Hypnotherapy
> Massage Therapy
> Mind-Body Medicine (using thoughts, emotions to influence health)
> Meditation (eg, mindfulness-based therapies)
> Nutrition (including nutraceuticals, dietary supplements)
> Osteopathy (not actually CAM but a complete system of medical care)
> Qi gong
> Relaxation Techniques
> Spirituality (including prayer)
> Tai Chi
> Touch Therapies (healing touch, therapeutic touch)
> Traditional Chinese Medicine
> Yoga
To the above list from the Bravewell Collaborative, the following might be added as being of possible importance and benefit for persons with pain:
> Art Therapy
> Biomagnetic Therapies
> Ergonomics (adapts tasks, tools, and environment to the comfort needs of the individual)
> Exercise (other than Yoga, Tai Chi, etc. listed above)
> Hot/Cold Treatments
> Journaling
> Music Therapy
> Occupational Therapy
> Orthotics (devices to support or correct limb/torso function)
> Physical Therapy (certainly important and not listed separately above)
> Psychotherapy (important and also not included separately above)
> Self-Help Support Groups
Considered together, the above “wish lists” are extensive and impressive. Could/should other modalities be added? (Readers, please comment below if any important modalities were left off.)

Our own position has been that the most vital role of the 3 major traditional modalities — pharmacotherapy, interventional medicine, and surgery — is to provide sufficient relief from pain (although often not 100% relief) so that the individual can actively participate in other modalities that address not only the physical but also mental and spiritual facets of the individual for a better quality of life. Unfortunately, while many options for achieving this holistic approach exist, there also are some formidable obstacles:
  1. Access — in most parts of the United States (and the rest of the world) access to pain treatment options is limited by selective availability; at best, only pharmacotherapy or surgery may be available. Even in large metropolitan areas, there are few multimodal pain practices offering a range of services or acting as central “clearinghouses” that can direct patients to the many therapies that might be of benefit — if those therapies are available for access in the community at all.
  2. Costs — public and private healthcare insurance plans generally will not cover expenses for chronic pain treatments considered to be outside mainstream medicine, including most CAM therapies. Therefore, many potentially worthwhile modalities are denied to large numbers of patients who do not have the financial resources to pay for such services out of pocket. Patients who are underinsured or uninsured may have difficulty accessing even the most basic pain management services, at least in the U.S.
  3. Efficacy — a growing body of evidence on CAM therapies supports their effectiveness, and more information is available from the National Center for Complimentary and Alternative Medicine (NCCAM) at the National Institutes of Health [here]. At the same time, however, most CAM modalities and certain other therapies are unregulated. Unfortunately, this creates opportunities for unscrupulous manufacturers and practitioners to promote useless or, worse, harmful treatments or devices without a solid footing in science or supported by clinical evidence of efficacy.

    A recent article by Deborah Barrett, PhD, MSW, LCSW, in FM AWARE, the magazine of the National Fibromyalgia Association, offers excellent guidance on “Steering Clear of Scams” [here]. As she notes, “When people suffer from problems with no easy answers, opportunity expands for quacks and scammers.” There is no “quick fix” for chronic pain conditions and she describes five “red flags” to watch for — advising patients to check with their healthcare providers about the safety of treatments they are considering.
  4. Responsibility — integrative, holistic, approaches to pain management of necessity place a burden of responsibility on patients (and, possibly, family caregivers). Patients must become involved in their own care, not only by following medical instructions, but also by seeking and actively participating in alternative or complementary approaches that may be of benefit. As much as anything, an integrative approach appears to hinge on what patients are able and willing to do to help themselves; it is the opposite of more traditional medical care that does something to the patient. Some patients may be unwilling or at a point where they are unable to accept such responsibility.
Despite the obstacles, it is still encouraging that there are so many options available for patients and their healthcare providers to choose among for better managing chronic pain conditions — if they choose to pursue them. From a holistic perspective, the Bravewell Collaborative suggests that health is more than the absence of disease or total freedom from pain, it is about achieving physical, mental, emotional, and spiritual wellbeing. Without such a healthful state, they observe, “we cannot easily share in loving relationships with our families and friends, fully participate in our chosen work, contribute meaningfully to our communities, or effectively compete on the global stage.” Perhaps, the greatest gift of a holistic approach is that a patient fraught with frustration and fear over a seemingly unrelenting chronic pain condition may become empowered and imbued with hope.