Audra Fox, MD OU Dept of Family Medicine 2012 Pain Summit 05 October 2012 Why do we need to discuss pain management options Introduce CAM / Integrative Medicine Define commonly misunderstood terms Discuss briefly the 5 domains as defined by the NIH Discuss at least one alternative option for pain management I have no financial disclosures or conflicts of interests. Time off work $$$ Addiction / Recovery Physician Liability Oklahoma specifically Does it work – pt satisfaction Condition Number of Suffers Source Chronic Pain 100 million Americans Institute of Medicine of The National Academies Diabetes 25.8 million Americans American Diabetic Association (diagnosed and estimated undiagnosed) Coronary Heart Disease 16.3 million Americans American Heart Association Stroke 7.0 million Americans American Heart Association Cancer 11.9 million Americans American Cancer society (Heart attack and chest pain) www.painmed.org American Pain Foundation evaluated the impact that chronic pain had on 303 chronic pain sufferers who sought care from their physician and were currently using an opioid to treat their pain Control Over Chronic Pain More than half of respondents (51%) felt they had little or no control over their pain. Six out of ten patients (60%) said they experience breakthrough pain one or more times daily, severely impacting their quality of life and overall wellbeing. Impact on Quality of Life Almost two-thirds (59%) reported an impact on their overall enjoyment of life. More than three quarters of patients (77%) reported feeling depressed. 70% said they have trouble concentrating. 74% said their energy level is impacted by their pain. 86% reported an inability to sleep well. The total annual incremental cost of health care due to pain ranges from $560 billion to $635 billion (in 2010 dollars) in the United States, which combines the medical costs of pain care and the economic costs related to disability days and lost wages and productivity The number of prescriptions filled for opioid pain relievers has increased dramatically in recent years. From 1997 to 2007, the milligram-per-person use of prescription opioids in the U.S. increased from 74 milligrams to 369 milligrams, an increase of 402%. In addition, in 2000, retail pharmacies dispensed 174 million prescriptions for opiods; by 2009, 257 million prescriptions were dispensed, an increase of 48% www.whitehouse.gov/ondcp #1 in the country – recreational painkiller use Approximately 240,000 Oklahomans (8% of the population) age 12 and above took prescription painkillers for nonmedical reasons over a 12month period On an average day, 2 Okies die from drug overdoses. More deaths from drug overdoses than MVA On any given day, 600-900 are waiting on bed in a publicly funded residential substance abuse center. $5.4 billion on indirect cost Absenteeism and reduced productivity $1.8 billion on direct cost Hospital, doctors, police, prisons Total: $7.2 billion In 1999, the NIH established the National Center for Complementary and Alternative Medicine (NCCAM) >800 studies funded at >130 institutions CAM use is Increasing 40-60% Americans use CAM each year Overwhelming majority seek care from their physician BEFORE they see an alternative provider Eisenberg DM et al Ann Intern Med 2001;135:344 Conventional / Western / Allopathic medicine practiced by holders of M.D. and D.O. degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses CAM – complementary and alternative “Healing philosophies, approaches, therapies that mainstream Western medicine does not commonly use, accept, study, understand or make available” Complementary - the use of CAM together with conventional medicine Alternative - use of CAM in place of conventional medicine Integrative - a practice that combines both conventional and CAM treatments for which there is evidence of safety and effectiveness Types of CAM Used by Americans Age ≥50 AARP/NCCAM Survey Massage, chiropractic or other bodywork Herbal products or dietary supplements Mind-body practices: hypnosis, meditation, etc. 45% $33.9 42% 15% Naturopathy, acupuncture, or homeopathy 14% BILLION Energy therapies, including magnets and Reiki 10% 2% Other 0% 10% 20% 30% 40% 50% 1. 2. 3. 4. 5. Biologically based Manipulative & Body-based Energy Medicine Mind-Body Medicine “Whole Medical Systems” Dietary supplements Botanicals / Herbal products Probiotics Derived from the leaves of the plant Used primarily to treat migraine headaches Recently, Aveeno skincare brand added feverfew to its Active Naturals line to calm red and irritated skin. 170 pts with migraine Randomized to receive 6.25 mg feverfew CO2-extract or placebo three times a day for 16 weeks Results showed that the frequency of migraines decreased by 1.9 attacks in the treatment group and by 1.3 attacks in those on placebo from 4.79 attacks per month. Difference was found to be statistically significant. The feverfew extract was well tolerated with nonspecific adverse effects that were seen in the placebo group as well. Researchers conclude that feverfew is effective in reducing the frequency of migraine attacks in patients. Some laboratory tests show that feverfew can reduce inflammation One study found that feverfew was no better than placebo in improving rheumatoid arthritis symptoms To prevent or stop a migraine: Take 100 - 300 mg, up to 4 times daily, standardized to contain 0.2 - 0.4% parthenolides supplements that are carbon dioxide extracted - take 6.25 mg, 3 times daily, for up to 16 weeks Rheumatoid arthritis: 120 - 60 drops, 2 times daily of a 1:1 w/v fluid extract 60 - 120 drops 2 times daily of 1:5 w/v tincture. Side Effects: Minor gastrointestinal distress. Oral ulcerations may result from chewing fresh feverfew leaves. Precautions: Feverfew may increase the risk of bleeding, especially if you take blood-thinning medications such as warfarin (Coumadin) or aspirin Capsaicin is believed to cause depolarization of C-fiber polymodal nociceptors thereby releasing substance P, which is a neurotransmitter that relays pain signals to the brain. The sensation of pain actually increases upon application of capsaicin due to release of substance P, but subsides when its levels are depleted at the afferent neurons Effective use of capsaicin requires topical application 4 or 5 times daily for a period of at least 4 weeks Uses: Arthritis, diabetic neuropathy, shingles, cluster HA 8-week double-blind, multicenter, parallel study with 235 pts Compared the safety and efficacy of topical capsaicin and oral amitriptyline in patients with painful diabetic neuropathy involving the feet. A visual analogue scale of pain intensity and measurements of interference by pain with functional activities were recorded at onset and at 2-week intervals. Topical capsaicin and oral amitriptyline produced equal and statistically significant improvements in pain over the course of the study. By the end of week 8, 76% of patients in each group experienced less pain, with a mean reduction in intensity of more than 40%. No systemic side effects were observed in patients treated with topical capsaicin. Most patients receiving amitriptyline experienced at least one systemic side effect, ranging from somnolence (46%) to neuromuscular (23%) and cardiovascular (9%) adverse effects. Topically applied capsaicin is an equally effective but considerably safer alternative to amitriptyline for relief of the pain of diabetic neuropathy. Topical: 0.025%-0.075% capsaicin creams may be applied three to four times a day and have a duration of action of about 4-6 hours. If applied with fingers, wash hands afterwards with a diluted vinegar solution. Connective tissue health and formation of collagen USES: Arthritis, cramps Dosage: 2-10 grams SE: No toxic effect shown in humans Oregon Health Science University animals that were given MSM showed no degeneration of cartilage associated with RA Alpha-lipoic acid acts as a lipophilic free radical scavenger Can assist in repairing oxidative damage and regenerate endogenous antioxidants such as vitamin C, vitamin E, and glutathione. DHLA and lipoic acid also have metal chelating capacities. Essential cofactor in the production of energy and acts as a potent antioxidant and exerts apoptotic effects on tumor cell lines . In human studies, alpha-lipoic acid improved insulin sensitivity, vasodilation, and polyneuropathy in patients with diabetes mellitus A meta-analysis of clinical trials of alphalipoic acid in diabetic patients showed a significant reduction in neuropathic symptoms A meta-analysis of clinical trials of alpha-lipoic acid and symptomatic polyneuropathy. Four trials met the stringent inclusion criteria (randomized, double-blind, placebo, using 600 mg i.v. per day for three weeks, except for weekends, in diabetic patients with positive sensory symptoms of polyneuropathy scored by the Total System Score in the feet on a daily basis). The analysis included 1258 patients following an intention-totreat principle. Improvement was first noted after eight days of treatment. After three weeks, responder rates for patients receiving alphalipoic acid was 53% versus 37% for placebo. The difference was statistically significant. Researchers suggest that alpha-lipoic acid may be clinically meaningful as a treatment for diabetic polyneuropathy. Dose: 300 mg BID Spinal manipulation Massage therapy “Movement Therapies” Feldenkrais method Alexander technique Pilates Rolfing Structural Integration Trager psychophysical integration Strain CounterStrain A 2008 review of 13 clinical trials found evidence that massage might be useful for chronic lowback pain A multisite study of more than 300 hospice patients with advanced cancer concluded that massage may help to relieve pain and improve mood for these patients. Prospective randomized trial, participants received 8 weeks of Swedish massage therapy showed significant improvement in pain, stiffness, and physical function. These improvements persisted to 16-week evaluation. Airrosti Applied Integration for the Rapid Recovery of Soft Tissue Injuries No / Limited Studies Post treatment survey Total Number of Patient Cases in 2011: 33,152 Average Treatment Duration: 2.9 Visits 99.7% of patients reported they would recommend Airrosti to friends and family. Did Airrosti Resolve Your Injury/Condition? 88.4% Did Airrosti Help Prevent a Recommended Surgery? 1,104 Did Airrosti Help Reduce/Eliminate the Need for Meds? 93% Did Airrosti Prevent Further Medical Services? 91% Magnet therapy Light therapy Qi gong Reiki Healing touch Ki Iki Jutsu Acupuncture Scientific evidence does not support the use of magnets for pain relief. Magnets may not be safe for some people, such as those who use pacemakers or insulin pumps, as magnets may interfere with the devices. Otherwise, magnets are generally considered safe when applied to the skin. Gentle touch assists in balancing your physical, mental, emotional, and spiritual well-being. The provider will ask a series of questions about the individual’s physical, mental, and emotional situation, and will answer any questions. Then the individual will lie fully clothed on a massage table while the provider gently places their hands slightly above or on the individual. The session generally lasts 40 to 60 minutes, and people frequently report feeling deeply relaxed and peaceful during and after the session. Several, small studies Focuses include: post-op healing and pain, muscle pain and spasms, depression, anxiety, abuse in women. One year study of 30 pts with End-Stage Liver Disease showed statistically significant improvement in pain and anxiety. Holistic Approach to Treatment of Intractable Central Neuropathic Itch 25 yo male who sustained a TBI “hundreds of mosquitoes biting me” Received 10 sessions of conventional high dose and aggressive pharmacotherapy and psychotherapy – 10/10 Bi-weekly HT for 1 month – 2/10 After 4 months of sessions, itch free. Low frequency sound waves used (7.83-13.5 Hz) over area of pain or injury. T.E.N.S : A study carried out concluded that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone. (N Engl J Med 1990; 322: 1627–34.) 2009 Cochrane systemic review of TENS for knee OA concluded that available studies were too small and poorly designed to judge its effectiveness. However, its use in tibiofemoral OA has yielded good results. The effect of foot reflexology on pain in pts with metastatic cancer: 36 oncology inpatients Foot reflexology was found to have a positive immediate effect for patients with metastatic cancer who report pain no statistically significant effect at 3 hours after intervention or at 24 hours after intervention. Further study is suggested for foot reflexology delivered by family in the home for management of cancer pain. Meditation Yoga Deep-breathing exercises Guided Imagery Hypnotherapy Progressive Relaxation Qi gong Tai Chi Tai Chi is a traditional style of Chinese martial arts that features slow, rhythmic movements to induce mental relaxation and enhance balance, strength, flexibility, and self-efficacy. Researchers from Tufts University School of Medicine: Patients over 65 years of age with knee osteoarthritis (OA) who engage in regular Tai Chi exercise improve physical function and experience less pain. In a long-term study comparing Tai Chi with regular exercise in patients with symptomatic OA of the knee, researchers found that those in the Tai Chi group showed greater improvement in pain, physical function, self-efficacy, depression, and healthrelated quality of life, with some improvements lasting as long as 48 weeks. The sixth most commonly used complementary practice among adults Randomized Trial at conducted by York University in the U.K for Yoga for chronic low back pain. 313 adults 12-week yoga program led to greater improvements in back function than did usual care. Naturopathy Homeopathy TCM - Traditional Chinese Medicine Ayurveda Belladonna: Throbbing HA Kali Biochromicum: Sinus HA Nux Vomica :Tension HA with N&V Rhus toxicodendron (Poison Oak) reduced tender points by 25% in patients with fibromyalglia following 4 weeks of treatment. Experimental studies on the effects of arnica preparations have demonstrated Antimicrobial anti-inflammatory respiratory-stimulant positive inotropic tonus increasing actions Clinical trials conducted suggest benefits of arnica for osteoarthritis and reduction in postoperative swelling and pain Randomized, double-blind, controlled, multicenter study 204 outpatients with osteoarthritis of the interpharyngeal joints. Patients were randomized to receive 5% topical ibuprofen or arnica gel 3 times daily for 3 weeks. Patients were also allocated a preset number of acetaminophen tablets to be used as a “rescue treatment” if the pain was unbearable. Study results indicated that the arnica gel was comparable to ibuprofen gel with respect to hand functional capacity, pain intensity, number of painful joints, duration and severity of morning stiffness, and acetaminophen consumption. The researchers concluded that arnica gel can be used as an alternative to ibuprofen gel in patients with osteoarthritis of the hand. Bruise reduction: Arnica ointment 20%, under occlusion, bid for two weeks Osteoarthritis: A 4 cm strip of arnica gel rubbed on affected joints TID for 3 weeks Internal use of arnica is not advised. The effects of arnica on the lungs, heart, and uterus have not been sufficiently tested to justify the risks associated with oral use. A fatal case of poisoning has been reported following ingestion of 70 g of arnica tincture. The FDA considers oral Arnica an unsafe herb. External use appears to pose no risk. Acupuncture aims to restore and maintain health through the stimulation of specific points on the body. Studies / Research – lots! Mummified body found along border of Austria & Italy – dated 3000 BC Had tattoo markings that correspond to current acu-points X-rays revealed arthritis of the lumbar spine 9 out of 15 pts “Rapid Cancer Pain Relief with Auricular Micro-Macro Technique” One of the worlds oldest medical systems Originated in India Recruiting participants with Breast Cancer at University of California, San Francisco Integrative Approaches to Cancer Survivorship Primary Outcome Measures: Change in the quality of life over 16 weeks with ayurvedic intervention. 107 patients with primary knee osteoarthritis Randomized to receive 800 mg/day ibuprofen or 2g/day C. domestica extracts for 6 weeks. Improvement in pain on level walking, pain on stairs, and functions of the knee assessed by time spent during a 100-m walk and going up and down a flight of stairs were the primary outcome measures. The authors reported significant improvement at 0, 2, 4 and 6 weeks compared with baseline values in both groups, with the exception of pain on stairs (p = 0.016). Adverse events also did not differ much between the groups (33.3% vs 44.2%, p = 0.36 with C. domestica extracts and ibuprofen). C.domestica extracts demonstrated efficacy and were safe compared with ibuprofen in the treatment of knee osteoarthritis Dosing: Cut root: 1.5 - 3 g per day Dried, powdered root: 1 - 3 g per day Standardized powder (curcumin): 400 - 600 mg, 3 times per day Fluid extract (1:1) 30 - 90 drops a day Tincture (1:2): 15 - 30 drops, 4 times per day Precautions: taking large amounts of turmeric for long periods of time may cause stomach upset and, in extreme cases, ulcers. People who have gallstones or obstruction of the bile passages should talk to their doctor (couldn’t find an explanation) Turmeric may lower blood sugar levels, so be careful in DM pts CAM – complementary and alternative “Healing philosophies, approaches, therapies that mainstream Western medicine does not commonly use, accept, study, understand or make available” Integrative - a practice that combines both conventional and CAM treatments for which there is evidence of safety and effectiveness Survey in 2007, 40 % used at least one form of CAM for their pain. Current Research CAM therapies for chronic low-back pain, including acupuncture, massage, spinal manipulation, and yoga CAM therapies for osteoarthritis pain, including prolotherapy, tai chi, and yoga Massage for chronic neck pain Acupuncture and spinal manipulation for chronic headaches Acupuncture and tai chi for fibromyalgia pain. Low-Back Pain Promising Evidence of Potential Benefit Acupuncture √ Massage √ Spinal Manipulation √ Progressive Relaxation √ Yoga √ Limited, Mixed, or No Evidence To Support Use Prolotherapy √ Herbal Remedies √ Promising Evidence of Potential Benefit Acupuncture Limited, Mixed, or No Evidence To Support Use √ Glucosamine/ Chondroitin √ Gamma Linolenic Acid (GLA) √ Herbal Remedies √ Balneotherapy (Mineral Baths) √ Tai Chi √ Promising Evidence of Potential Benefit Acupuncture √ Spinal Manipulation √ Feverfew Limited, Mixed, or No Evidence To Support Use √ Neck Pain Promising Evidence of Potential Benefit Limited, Mixed, or No Evidence To Support Use Acupuncture √ Spinal Manipulation √ Questions? http://www.mskcc.org/cancercare/herb/alpha-lipoic-acid http://www.mskcc.org/cancercare/herb/turmeric http://www.ncbi.nlm.nih.gov/pubmed/196787 80 http://www.mskcc.org/cancercare/herb/feverfew http://www.ncbi.nlm.nih.gov/pubmed/162321 54 http://www.ncbi.nlm.nih.gov/pubmed/101503 23 http://www.nejm.org/doi/full/10.1056/NEJM1 99006073222303 http://www.ncbi.nlm.nih.gov/pubmed/14608 562 http://www.sciencedaily.com/releases/2009/10/0 91029102417.htm http://www.ncbi.nlm.nih.gov/pubmed/22041945 http://www.ncbi.nlm.nih.gov/pubmed/18607237 http://www.ncbi.nlm.nih.gov/pubmed/15261979 Harris, et. Chronic Pain Perspectives: A supplement to the Journal of Family Practice. September 2011. Vol 60, No 9.