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Integrator Report: Complementary and Alternative Medicine Inclusion in the IOM Nat'l Pain Blueprint PDF Print E-mail
Written by John Weeks   

Integrator Special Resource: Inclusion of "Complementary and Alternative Medicine" in the IOM National Blueprint on Pain Care, Education and Research

Summary: While consumer and practitioner use of complementary and alternative medicine (CAM) and integrative practitioners are each growing, one cannot yet assume that these disciplines and modalities will be included in clinical or policy strategies unless they are explicitly included. So when the Institute of Medicine (IOM) delivered its national strategic document on the massive issue of pain on June 29, 2011, "Relieving Pain in America: A Blueprint for Transforming, Prevention, Care, Education and Research," I explored the document for evidence of CAM/integrative inclusion. To what extent are these widespread consumer choices included in this strategic document? Here is an Integrator Special Resource, with all the specific language in the 15 relevant segments. What do you think of the inclusion, or the report in general?
Send your comments to
for inclusion in a future Integrator.

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Quasi-public agency sets agenda
Millions of consumers with pain conditions choose to see chiropractic doctors, massage therapists, integrative medicine doctors, acupuncturists, Yoga therapists and other distinctly trained so-called "complementary and alternative medicine" (CAM) practitioners as part of their care.

So when the Institute of Medicine of
the National Academies published what is to be a national strategy for pain on June 29, 2011, I was curious. Does the report, Relieving Pain in America: A Blueprint for Transforming, Prevention, Care, Education and Research, appropriately reflect consumer use and the roles of these disciplines? Because we still live in a time when "CAM" use needs to be explicitly included to not be dismissed, I searched the document for "complementary and alternative medicine" and a range of related terms. Below are my methods.
Search terms and report format: The following yielded some hits: "complementary and alternative medicine", "CAM", "chiropractic", "massage", "acupuncture", "naturopathic", "nutrition", "diet". I include those that are in the text (not merely in references) below. I also searched for "mind-body". This term is used 4 times, often not as a treatment, but as an approach. I comment on it separately in #15 below. I also searched for "integrative medicine", "integrative health care" and "integrative practitioner". These terms only showed up in references and thus are not included here.
Below are the 15 places I found these terms. I follow with some commentary. What do you think of this level of inclusion? What do you think of the IOM blueprint, generally?
_______________________________


Explicit Inclusion of "Complementary and Alternative Medicine" and Related Terms

in the IOM Report Calling for a "Cultural Transformation" on Pain Care, Education & Research

Note: All of the Section numbers are from the pre-publication PDF that is available for download here.


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Cover of the IOM's Blueprint for Pain
1.  In Summary Section, under Education Challenges (9)


Educational programs for the many types of health care professionals who play a role in pain prevention and treatment-nurses, psychologists, physicians, dentists, pharmacists, physical therapists, and complementary and alternative medicine practitioners-vary in the amount and quality of information on pain they contain. In medical education, pain generally has received little attention, which has contributed to the problem of undertreatment. The need for improved education about pain is especially acute for primary care providers-the front-line clinicians for most people's acute or chronic pain problems.

2.  Section 1, Introduction, under Clinician Level Barriers (24)

Clinicians can, in theory, draw on many disciplines in addressing the pain-related needs of individuals and families: physicians of several specialties, nurses, psychologists, rehabilitation specialists (physiatrists, physical therapists, and occupational therapists), clinical pharmacists, and complementary and alternative medicine practitioners (chiropractors, massage therapists, and acupuncturists, for example). Yet while a substantial amount of acute and chronic pain can be relieved with proper treatment by a single clinician or the appropriate mix of trained professionals, providers encounter a number of barriers to appropriate pain care:
Same page, under the list of barriers:

Should primary care practitioners want to engage other types of clinicians, including
physical therapists, psychologists, or complementary and alternative medicine
practitioners, it may not be easy for them to identify which specific practitioners are
skilled at treating chronic pain or how they will do so.

3.  In Section 2, Pain as a Public Health Challenge: Under "Costs to the Nation" (33)

Finally, as noted previously, people with chronic pain are frequent users of complementary and alternative medicine (CAM) services. The costs of these services-which often must be paid, at least in part, out of pocket-are difficult to measure or compare with those of conventional care. Washington State, where private insurance coverage of all licensed CAM providers is mandated, offers a unique opportunity to use insurer claims data to compare costs for those who use CAM for at least part of their care and those who do not. Such a study was performed on 2002-2003 data for insured individuals with back pain, fibromyalgia, and menopause symptoms, matching 26,466 CAM users with 13,025 nonusers on a 2:1 basis. Overall, CAM users had lower average expenditures than nonusers ($3,797 versus $4,153). Their outpatient expenses were higher, but offset by lower expenses for inpatient care and imaging. People who had the heaviest disease burdens accounted for the highest levels of savings, an average of $1,420. The study findings are suggestive, but limited because they do not reveal long-term costs or health outcomes (Lind et al., 2010), and longer-term studies would help clarify these potential savings.

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Lonnie Zelzer, MD: Integrative MD and IOM Committee member
4.  In Section 3, Care of People with Pain, under Self-Management (4)

To illustrate, back pain self-management efforts might include brief rests, resumption of normal activities, strengthening exercises, structured physical activity, application of heat and cold, use of over-the-counter medications and topical ointments and creams, sleep, yoga, and caution in lifting and carrying.


5.  In Section 3, Care of People with Pain, under Self-Management (5)

A self-management program of cognitive-behavioral therapy and diet interventions for women with irritable bowel syndrome, using advanced practice nurses, reduced abdominal pain symptoms (Heitkemper et al., 2004).


6.  In Section 3, Care of People with Pain,
under "Interdisciplinary teams" (7-8)

Interdisciplinary teams. Ideally, most patients with severe persistent pain would obtain pain care from an interdisciplinary team, as opposed to a specialist who might focus on a narrow range of treatments and have a restricted view of how pain is affecting the patient. The interdisciplinary model incorporates assessment and diagnosis, not just therapy. It is an integrated, coordinated, and multimodal approach to care targeting multiple dimensions of the chronic pain experience-including disease management, reduction in pain severity, improve functioning, and emotional well-being and health-related quality of life-that is developed through a comprehensive evaluation by multiple specialists (usually physicians, nurses, psychologists or other mental health professionals, rehabilitation specialists, and/or complementary and alternative medicine [CAM] therapists). In the primary care setting, the team most often includes a primary care practitioner, nurse, and mental health clinician. In specialty and tertiary care settings, this team approach most often emphasizes psychological, pharmacological, and rehabilitation approaches.

7.  In Section 3, Care of People with Pain, under Treatment Modalities, "Rehabilitative/Physical Therapy" (18)

Physical modalities of therapy include physical and functional restoration techniques, massage,  ultrasound, and neurostimulators (such as transcutaneous electrical nerve stimulation, or TENS). Other modalities include dry land physical therapy and aquatherapy.


8.  In Section 3, Care of People with Pain, under Treatment Modalities
, "Complementary and Alternative Medicine" (18-20)

Note: This is the 6th in a list, and is followed by a note on the placebo effect.

Definitions of CAM differ. For example, a study of CAM in hospices identified practices as diverse as massage therapy, supportive group therapy, music therapy, pet therapy, and guided imagery or relaxation, not all of which are usually associated with CAM (Bercovitz et al., 2011). Acupuncture, chiropractic spinal manipulation, magnets, massage therapy, and yoga often are considered CAM pain treatments. According to the National Institutes of Health's (NIH) National Center for Complementary and Alternative Medicine, additional CAM therapies used for pain include dietary supplements, such as glucosamine and chondroitin intended to improve joint health; various herbs; acupuncture; and mindbody approaches, such as meditation and yoga (NIH and NCCAM, 2010).

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Rick Marinelli, ND, LAc: Integrative clinician and IOM Committee member
CAM holds special appeal for many people with pain for several reasons:deficits in the way that many physicians treat pain, using only single modalities without
attempting to track their effectiveness for a particular person over time or to coordinate diverse approaches; 􀁸 the higher preponderance of pain in women (see Chapter 2), given that "women are more likely than men to seek CAM treatments" (IOM, 2005, p. 10); and 􀁸 a welcoming, less reserved attitude toward people with pain on the part of CAM practitioners and an apparent willingness to listen to the story of a patient's pain journey. Whatever the reasons, pain is a common complaint presented to CAM practitioners (NIH and NCCAM, 2010). In 2007, 44 percent of people with pain or neurologic conditions sought help from CAM practitioners (Wells et al., 2010). In 2002, three-fifths of people who turned to CAM for relief of back pain found a "great deal" of benefit as a result (Kanodia et al., 2010). The National Center for Complementary and Alternative Medicine's strategic plan, released in February 2011, supports the development of better strategies for managing back pain, in particular.

However, a single CAM practice, like a single type of medical treatment, may not be as beneficial as an integrated approach. It is unclear which types of patients-defined on the basis of pain condition, attitude, or other characteristics-stand to benefit most from CAM treatments for pain.

For which pain conditions are CAM treatments most often used? In the 2007 National Health Interview Survey (NHIS), adults reported using CAM in the previous year most often to treat various musculoskeletal problems. Just over 17 percent of adults-more than 14 million Americans-used CAM for back pain/problems; almost 6 percent (5 million) for neck pain/problems; 5 percent for joint pain/stiffness (5 million); and 44 percent specifically for arthritis (3 million). An additional 1.5 million used CAM for other musculoskeletal problems, 1 million for severe headache or migraine, 11 million for "regular headaches," and 0.8 million for fibromyalgia (Barnes et al., 2008). Rates of reported use of CAM for these conditions remained relatively unchanged since 2002. Even among children, NHIS data show that CAM therapies are used most often for back or neck pain (7 percent of all children).7 CAM treatments lie outside the traditional medical model, and research on their effectiveness for specific pain conditions is incomplete but accumulating. For example, reviews of research on acupuncture, massage, and chiropractic spinal manipulation for chronic low back pain suggest these therapies may be beneficial, whereas results are mixed as to whether the popular dietary supplements glucosamine and chondroitin sulfate can relieve osteoarthritis pain. Evidence regarding the effectiveness of static magnets, widely marketed for pain control, does not support their use. Systematic reviews show that spinal manipulation for low back pain is more effective than sham manipulation, bed rest, or traction, but not more effective than analgesics, physical therapy, exercise, or "back-school" education (Tan et al., 2007). Evidence also supports the use of massage therapy for low back and shoulder pain and suggests it may benefit patients with fibromyalgia and neck pain. Acupuncture appears to affect several mechanisms in the brain and spinal cord, including those involved in pain and inflammation. A systematic review supports its use in postoperative pain management (Sun et al., 2008). Likewise, German clinical trial involving more than 3,000 patients with chronic low back pain found that acupuncture improved functioning (Witt et al., 2006). A systematic review of 11 studies suggests that acupuncture may be clinically valuable in treating tension headaches (Linde et al., 2009).

Research on acupuncture has been controversial. Of interest, a systematic review of
23 clinical trials found moderate evidence that acupuncture and sham acupuncture are, in roughly equal measure, more effective than no treatment for chronic low back pain (Yuan et al., 2008). This finding is consistent with evidence from a rigorous German study (Haake et al., 2007). The success of sham acupuncture, in which needles are inserted in the body but not at acupuncture points and usually not with stimulation, has led to debates among researchers and clinicians about the value of placebos (Berman et al., 2010) (see the next section). Some critics of studies finding a lack of efficacy for acupuncture contend that the study findings are based only on criteria of Western medicine, not those of traditional Chinese medicine (Chiang et al., 2010). Evidence on the effectiveness of CAM in treating children's pain is not yet robust, although the available findings suggest that hypnosis, music therapy, acupuncture, laughter therapy, and massage therapy have been beneficial for acute procedural pain in children (Evans et al., 2008).

A systematic review found sufficient evidence to support only one CAM approach in children-the use of self-hypnosis/guided imagery/relaxation for recurrent headache (Tsao and Zeltzer, 2005). A review of 23 randomized controlled trials and eight meta-analyses on acupuncture for children found "evidence of some efficacy and low risk," with the greatest effectiveness found in preventing postoperative nausea (Jindal et al., 2008, p. 431). The authors caution, however, that "because acupuncture's mechanism is not known, the use of needles in children becomes questionable" (Jindal et al., 2008, p. 432). A study of 45 children found their expectations for benefits from CAM to be fairly low, and those of their parents only somewhat higher (Tsao et al., 2005).

9.  In Section 3, Care of People with Pain, under Note on the Use of Placebos (20-21)

Placebos conceivably could be considered a form of treatment of pain, especially in light of the shortcomings of other modalities or other benefits they bring in their own right. Even though placebos are believed to have no specific pharmacologic effects, researchers and clinicians have found that some people with pain have reduced symptoms after taking them and that at times, a placebo performs as well as-or better than-other treatments (see the above discussion of sham acupuncture). Furthermore, a placebo effect has been observed in the management of a variety of non pain disorders, suggesting that placebos have an effect that is yet to be fully understood on a scientific basis. A recent survey showed that many physicians already use placebos, in one form or another, in clinical practice (Tilburt et al., 2008), although the ethics of such use, when it involves deception, are rigorously disputed (Nichols et al., 2005). Certainly placebo should not be used as a diagnostic tool or to validate whether a patient's reported pain "is real or not." Neuroimaging studies show that placebos reduce activation of opioid neural transmission in pain-sensitive regions of the brain, which suggests that they do have biological effects (Qiu et al., 2009). According to Tracey (2010, p. 1277), the "placebo effect" is "a genuine psychobiological event attributable to the overall therapeutic context in which a treatment is given, which itself comprises many factors such as patient-physician interaction and treatment environment." One factor in the success of a placebo-or any pain treatment, for that matter-is the prescriber's empathy or skill in communicating with the patient. Evidence suggests that for patients treated with placebo pills, a positive relationship with a practitioner improves outcomes (Kaptchuk et al., 2008) and, in a sense, engages the brain to help in pain control by instilling optimism and confidence. Because placebo use could undermine trust, Kaptchuk and colleagues (2010) told patients they were receiving a placebo, and the treatment still produced statistically significant improvements in terms of mean global improvement scores, reduced symptom severity, and adequate relief at both an 11-day midpoint and 21-day endpoint (Kaptchuk et al., 2010).


Image10.  In Section 3, Care of People with Pain, under Reporting of Pain (31)

Depending on the severity of the pain, its site, local access to clinicians, insurance coverage, lifestyle, and pattern of health care use, people also may bring the complaint to one or more of the following:
  • hospital EDs;
  • medical center-based or free-standing ambulatory care clinics;
  • physiatrists (physicians specializing in physical and rehabilitation medicine) or physical therapists;
  • dentists;
  • psychotherapists, including psychiatrists, clinical psychologists, clinical social workers, and psychiatric/mental health nurses;
  • pharmacists;
  • chiropractors;
  • podiatrists;
  • occupational health nurses;
  • school nurses;
  • substance abuse clinics and drug and alcohol counselors; and
  • massage therapists, acupuncturists, and various other CAM practitioners (and vendors)
11.  In Section 4, Education Challenges, Under Other Health Professions Education (26-27)

Because complementary and alternative therapies are widely used in pain care (see Chapter 3), the education of CAM practitioners is an important component of health professions education about pain and pain management, although systematic reviews of this training are scant. In general, education and training of CAM practitioners is less formal than that of physicians, nurses, and other conventional health professionals, in part because of the lack of accreditation standards for CAM education programs, the existence of many small proprietary training programs, and a chaotic set of state licensure regulations for CAM practitioners (Kreitzer et al., 2009). Thus, for example, substantial variation has been found in pain education among chiropractors and acupuncturists (Breuer et al., 2010). Few educational programs in state-licensed CAM fields involved in pain care-chiropractic, acupuncture, naturopathic medicine, traditional Chinese medicine, and massage therapy-appear to focus specifically on pain and pain management. However, several interdisciplinary
undergraduate and graduate degree or certificate programs have emerged that allow for a focus on pain in CAM practice. For example, a collaborative program sponsored by Tufts University School of Medicine and the New England School of Acupuncture provides an opportunity for master's students in acupuncture to enroll in a multidisciplinary pain management program at Tufts (White House Commission on Complementary and Alternative Medicine Policy, 2002). Several organizations representing CAM practitioners and others who offer pain treatment (e.g., the American Holistic Medical Association, American Association of Orthopaedic Medicine, and American Association of Naturopathic Physicians) are able to contribute to the education of relevant stakeholders.

12.  In Section 5, Research Challenges, Under Comparative Effectiveness Research (14)

CER also holds promise for informing pain-related public policy. To date, however, it has
been used almost exclusively to test medical and surgical treatments for pain. For these studies to
be useful in informing policy decisions at both the individual and population levels, their focus
needs to be expanded so as to test the effects of psychosocial interventions for pain relief relative
to one another and to other medical, rehabilitative, and complementary and alternative medicine
(CAM) approaches.

13.  Under Annex #1, Research Objectives, Paragraph #1

New and innovative advances are needed in every area of pain research, from the microperspective of molecular sciences to the macro perspective of behavioral/social sciences. Although great strides have been made in some areas, such as the neural pathways of pain, chronic pain and the challenge of its treatment have remained uniquely individual and largely unsolved. Proposals that seek to improve the understanding of the causes, costs, and societal effects of both acute and chronic pain and the relationships between the two are highly encouraged. Studies on the mechanisms underlying the transition from acute to chronic pain are also needed. Additionally, proposals that link such understandings to the development of better approaches to therapeutic interventions, including complementary and alternative medicine (CAM) interventions, and management of acute and chronic pain are in keeping with the current translational focus of NIH and are encouraged.

14.  In Summary of Testimony, under Reimbursement Policies (B-6)

A neurologist and pain medicine specialist sums up what many providers agree are some of the primary barriers to effective pain treatment: "1) too many pain providers give onedimensional care; 2) patients often expect simplistic answers or injections; 3) medical providers too often refer pain patients to specialists (e.g., orthopedic surgery) rather than to a comprehensive pain center; 4) multi-disciplinary pain treatment is not well-developed throughout the country." Another pain specialist-and director of a pain clinic-decries how "cost cutting has led to limited access to modalities such as injections, neuromodulation, chiropractic care, mental health care, massage, and acupuncture for chronic pain." An internist notes, "it seems easier to get help with chronic diabetics or heart failure patients, but not the same kind of support for chronic pain patients."

15.  Notes on the Use of "Mind-Body" in the Report


A search for "mind-body" netted 4 responses. Most did not refer to specific therapies or treatments, but rather to an approach to pain. The phrase is used in dismissing a Cartesian view of the mind0-body separation. (1-15) The term is used to describe the newly accepted approach to pain: "This mind-body perspective is now generally accepted by pain researchers." (3-12). It is listed as an Essential Patient Education Topic: "The fact that pain involves a complex mind-body interaction, rather than being strictly physical (biologic) or strictly emotional (psychological)." (4-3) The term is used similarly, under public education strategies. (4-9) Note that behavioral approaches are widely referenced.


_________________________________
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Consortium's view of medicine supported here
Comment
:
When the IOM began this project in late 2010, an early question was whether the complementary, alternative and integrative disciplines and therapies would be represented on the IOM's consensus committee. The Academic Consortium for Complementary and Alternative Health Care, with which I am involved, was among those who sought to help educate the IOM team to the important role "CAM" therapies and providers have in consumer choice around pain conditions. Think how many, often as their first choice, see chiropractic doctors, massage therapists, acupuncture and Oriental medicine professionals, Yoga therapists and, for gut-related pain in particular, naturopathic and integrative physicians.

To their credit, IOM staff, led by senior program officer Adrienne Stith-Butler, convened a committee that included experts in these areas. (See
IOM Pain Committee includes integrative MD Lonnie Zeltzer and Rick Marinelli, ND, LAc.) Whether this level of inclusion of "CAM" in the text was the result in some ways of these members being present cannot be known. Marinelli, in an informal comment after the 2nd committee meeting, shared that he found other members of the committee to be generally appreciative of the potential role of these approaches.

The more important perspective in this report for the integrative practice community is the expressed support for a mind-body framework of understanding pain. This shapes recommendations for multidisciplinary, multi-modality approaches. To this extent, the report may be seen as an endorsement of an approach to medicine affirmed in the Definition of Integrative Medicine promoted by the Consortium of Academic Health Centers for Integrative Medicine
"Integrative Medicine [optimal pain treatment?] is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing." [Brackets added.]
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Myra Christopher: Committee member leads effort to put recommendations into practice
A long-time integrative medicine colleague who has been in clinical practice for 25 years read the report thoroughly. I asked his perspective and he replied: "I hate to say it but the document does not really say all that much. They just can't get their collective mind around the fact that much of the treatment and management of pain requires good hands and a good exam, and that most docs are simply afraid of pain. Thus, they seize up and default to prescriptions and referrals."

Your thoughts? 


Final note: Those interested in one effort to effect the study recommendations may be interested in following the Pain Action Initiative of the Center for Practical Bioethics. The not-for-profit is led by Myra Christopher, an
IOM Committee member for the pain report. As a participant in Christopher's work under my ACCAHC hat, I can state that her initiative, while pharma-sponsored, is open to participation from the integrative practice fields.

Send your comments to
for inclusion in a future Integrator.


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