Pain is a universal human experience and one of the most common reasons people see a doctor. It has repeatedly been in the news due to the current opioid epidemic that is taking the lives of more than 90 people a day in the United States.
On May 31 the head of the National Institutes of Health, Dr. Francis S. Collins, and the head of the National Institute on Drug Abuse, Dr. Nora Volkow, published an article in the New England Journal of Medicine, titled “The Role of Science in Addressing the Opioid Crisis.” Sadly, the only science addressed concerned pharmaceutical drugs.
{mosads}That narrow focus is out of step with current recommendations from major public health organizations, including the CDC, FDA and the Joint Commission, that non-pharmacologic approaches to pain be first-line treatments.
For example, the American College of Physicians, which represents internal medicine doctors, published practice guidelines for low-back pain in February 2017, stating:
For patients with chronic low-back pain, clinicians and patients should initially select non-pharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence).
It is, therefore, extremely disconcerting to read the complete omission of non-pharmacologic treatment by the leadership of NIH and NIDA, who have enormous influence on what is researched and therefore on what is brought into policy and practice.
Cannabis and deep brain stimulation are mentioned in the article; however, cannabis has legal challenges at the federal level as well as in multiple states, and deep brain stimulation is highly invasive. The most cost-effective and least invasive practices, which need and deserve further research, are completely ignored.
Opioids are the best medications we have for moderate-to-severe acute pain; used appropriately, they are effective and relatively safe. As stand-alone treatment for chronic pain, however, they neither safe nor effective. With more and more patients seeking relief from chronic pain syndrome, doctors have come to understand that it is fundamentally different from acute pain.
As pain becomes chronic, brain areas that perceive it begin to change physically and communicate with nearby areas that normally have nothing to do with pain. Involvement of these other regions appears to be related to difficult symptoms that often accompany chronic pain, such as fatigue, disturbed sleep, depression, anxiety and cognitive impairment. These co-morbidities greatly complicate the management of chronic pain. In many settings, unfortunately, patients with chronic pain syndrome are still treated as if they had acute pain.
The newer, integrative approach stresses individualized treatment, using many different modalities coordinated by a team of healthcare professionals. Analgesic medication is a component of this approach but never the sole component or even the most important one.
An example is the Oregon Pain Management Commission’s integrative initiative. Based on the costs and poor outcomes of a medication-focused approach, the state passed an initiative in 2016 to provide integrative therapies for chronic pain syndrome in addition to conventional care, including acupuncture, massage, manipulation, yoga and supervised exercise and physical therapy. It left out mind/body therapies, such as hypnosis, biofeedback and mindfulness-based stress reduction, which can be both cost- and time-effective.
The Veterans Administration (VA) has also backed away from reliance on opioids to manage chronic pain syndrome and is now actively promoting comprehensive care that includes acupuncture, yoga, mindfulness meditation and physical therapy. Other states should follow the lead of Oregon and the VA, mandating policies that address the new science of chronic pain with integrative approaches rather than punishing users or prescribers of analgesic medication.
Additional policy changes would support funding not only for pharmaceutical-government partnerships as promoted by NIH leaders, but also for cost and clinical effectiveness outcomes research that could be carried out in partnership between innovators and insurers.
In addition, funding is needed to assess the impact of new educational programs on integrative pain management. These would evaluate changes in prescribing behavior of providers and the use of opioids as well as satisfaction with care amongst the patients they serve.
Broadening our perspective so as to address prevention, training and best medical practices is critically important for the institutions that determine research priorities and drug policy.
Andrew Weil, MD, is director of the University of Arizona Center for Integrative Medicine and author of “Mind Over Meds: Protect Yourself from Overmedication by Knowing When Drugs Are Necessary, When Alternatives Are Better, and When to Let Your Body Heal on Its Own.” Victoria Maizes, MD, is the executive director of the University of Arizona Center for Integrative Medicine and a professor of medicine and public health.
The views expressed by contributors are their own and not the views of The Hill.