Useful Alternative and Complementary Therapies for Treating Chronic Pain
--By: Michael Joseph, M.D.--
Event_Moderator: Welcome to WebMD Live. Today Lonnie Zeltzer, M.D., will be discussing "The New Millennium: What Alternative and Complementary Therapies Are Useful For Treating Chronic Pain" with Michael Henry Joseph, M.D.
Michael Henry Joseph, M.D., is an Assistant Professor of Pediatrics and Co-Director of Chronic Pain Services at UCLA Children's Hospital in Los Angeles. He served his residency at UC Irvine where he was a clinical instructor. He received a fellowship to study Pediatric Pain Medicine at UCLA. He is also a past recipient of The Golden Apple Award for Excellence in Teaching in 1997.
Lonnie Zeltzer, M.D., is an expert in the field of pediatric pain. She is currently a Professor of Pediatrics and Anesthesiology at the UCLA School of Medicine and the Director of the UCLA Pediatric Pain Program and Associate Director of the Patients & Survivors Section, Cancer Prevention and Control Research Branch of the UCLA Jonsson Comprehensive Cancer Center.
Event_Moderator: Dr. Joseph and Dr. Zeltzer, welcome to the show.
Dr_Zeltzer: Welcome
Dr. Joseph: Welcome everyone. Today we will be discussing how Alternative and Complementary Medicine can be used in the treatment of chronic pain. I have asked Dr. Joseph to join me.
Dr. Joseph is the Co-director of the UCLA pediatric pain clinic. The clinic is a unique model of the blending of biomedicine with alternative medicine. The multidisciplinary team work optimizes patient care by combining therapies from many disciplines. We welcome your questions regarding the application of different alternative therapies, how they might benefit chronic pain, or how best to combine alternative and biomedicine therapy.
Event-Moderator: [question presented] What makes the therapy alternative or complementary?
Dr_Joseph: The terms are problematic. The National Institute of Health defines alternative therapy as anything that is unproven. I really don't like that designation. I think the question should not be what is proven or unproven but what is good medicine or bad medicine. I believe that all therapies can be complementary. There are certainly situations where two therapies might not be used together. But this is rare. I think we should just use the term complementary when we refer to any non-biomedical therapies.
Dr_Zeltzer: Can complementary therapies interact or interfere with biomedical medicine or each other?
Dr_Joseph: It is not proven but there are theories that certain complementary medicine techniques can interfere with biomedical medicine. The basic philosophy of therapies such as acupuncture is to bring the bodies' functioning back to its normal baseline. There are times in biomedical therapy such as times when you want someone to be tumor suppressed or immuno suppressed after a transplant that you don't want their body to be in its normal state. There is no actual proof that acupuncture will interfere with immuno suppression, but we don't recommend that it be done in such patients.
Dr_Zeltzer: An example of the two kinds of therapies that might not be helpful to each other would be using acupuncture which helps the body's own pain control system work well in part by increasing the body's production of endorphins. However, if the patient also is taking opioids, that is narcotics like morphine or oxycodone, then the opioids will block the body's own production of natural narcotics. ...like endorphins. So in this case, there are two opposing therapies. Another example of possible toxicity are the use of St. John's Wort and herbal therapy for depression and also used for pain control and Prozac, since the chemicals in both are the same or very similar. And using both at the same time might produce toxic levels of that chemical in the blood.
Event_Moderator: [question presented] Should my acupuncturist or any other clinician providing complementary therapy for me speak with my medical doctor?
Dr_Joseph: Yes. I think it is essential that anyone who's treating you, whether it is your biomedical doctor or complementary medicine practitioners, should always coordinate therapies and speak with each other.
Dr_Zeltzer: What do I say to my doctor if he or she discourages me from participating in alternative therapies?
Dr_Joseph: That's a more difficult question. I think that it is essential that you let your doctor know that you are interested in alternative therapies, complementary therapies, and you have them understand that you feel that it's important to your treatment and give them the opportunity to learn about the therapies by speaking with your complementary medicine practitioner.
Dr_Zeltzer: There are so many different therapies, how do I know which ones work for my chronic pain problem?
Dr_Joseph: There are both proven therapies and by proven I mean, there have been scientific studies as well as reports and anecdotal studies of complementary medicine therapies. Therapies that are known to be helpful include such things as acupuncture for chronic headache or for period cramps. Acupuncture has been shown to be helpful in both of these conditions. Also, biofeedback with or without relaxation therapy, has been shown to also be very helpful for chronic headache. In fact, cognitive behavioral therapy has been shown to be more effective for migraines in adolescents than medication. There is also proof of massage being therapeutic, improving lymphatic flow as well as regional blood flow and releasing muscle pain. Other therapies that we have found to be helpful in clinic, although there is little proof, are bioenergy healing, yoga, movement therapy, Reiki healing, acupuncture, acupressure, meditation.
Dr_Zeltzer: The problem with the issue of proven or not proven therapies relates to how recently these alternative and complementary therapies have come into public limelight. And, in a sense, the public's interest in use of these therapies have pushed the government and other funding agencies to begin reporting research studies of these therapies. Thus some like acupuncture are starting to gain recognition because they have thus far, been studied the longest. Other treatments like bioenergy therapy have not been rigorously studied at all. I believe that as more research in these treatments continue, we will shift treatments that were in the unproven category into the proven categories over time. So we are only speaking about what is known up to this point.
Dr_Zeltzer: What is acupuncture or biofeedback or massage therapy beneficial for?
Dr_Joseph: We answered that somewhat in the last question. Acupuncture has been shown to be helpful for chronic headache, menstrual cramps. The way that it is thought to work from a biomedical standpoint is by increasing natural pain killing molecules called endorphins...as well as changing regional blood flow. Biofeedback has also been shown to be extremely helpful in chronic headache. And not just migraines but chronic headaches of any form. It may very well be the most beneficial therapy even moreso than medication. Massage has been shown to be beneficial for releasing muscle pain, increasing general well-being and improving lymphatic flow.
Event_Moderator: [question presented] In your experience, how much of chronic pain is psychosomatic?
Dr_Joseph: Good question. All chronic pain comes from a mind/body interaction. Pain is experienced and is a perception. That perception exists solely within your mind, no matter the reason for the pain. If you stub your toe, the pain is perceived in your brain. So, in essence, all pain is in your head. Certainly, no matter what the cause of chronic pain is, it eventually has psychological ramifications and psychological stress always makes the body more prone to develop chronic pain.
Dr_Zeltzer: I want to add that there are sophisticated radiologic imaging techniques such as a PET scan that can demonstrate areas in the brain where pain is perceived. So even experiences like pain perception that are clearly in the mind and have emotional and cognitive (thinking) components still have a biological basis that makes the experience happen.
Event_Moderator: [question presented] How do you first approach a patient who comes to you complaining of chronic pain?
Dr_Joseph: We always approach a patient looking at what we call the biopsychosocial method. What that means is that during our evaluation we ask questions as well as do a physical examination or laboratory studies sufficient to assess not only what is going on inside the patient but also what's going on psychologically with the patient, in addition to what is going on around the patient in their life, loved ones, school or their friends. We believe that without assessing each one of these components you cannot fully understand or adequately treat a chronic pain problem.
Dr_Zeltzer: This is why we always see all new patients, meaning a child together with his/her family or at least one or two parents, together with our pain program psychologist, Dr. Brenda Bursch...so that from the start we employ a mind/body approach in both the evaluation and the treatment. We see chronic pain as a large puzzle with many components as Dr. Joseph mentioned. And to treat chronic pain effectively, it is important to understand all of the components, not only how the pain started but also what might be contributing to keep the pain going. We also learn about how the pain is impacting the life of the child and family. All of these pieces of information are important in putting together a complete treatment plan.
Event_Moderator: [question presented] Define chronic pain.
Dr_Joseph: Chronic pain...not an easy definition. First, to define pain itself is not an easy thing. Pain has been described as the response to the perception of tissue damage within the body. That's a vague statement mainly because the true understanding of pain, other than a signal that there is a threat or harm to the body, is not well defined. The definition of whether pain is acute or chronic adds yet another dimension of difficulty. Some people have defined it as pain that simply lasts longer than expected. That brings up how can one expect pain to last for any length of time when we don't really understand what it is. Different pain states such as fibromyalgia have time periods defined within them; the adult criterion requiring pain for six months and the child criterion requiring pain for three months. So, in essence, whether pain is chronic or not depends on the type of pain, the age of the patient, as well as how the pain started and any number of other factors, but it is really on an individual basis that that determination is made.
Event_Moderator: [question presented] Doesn't part of the healing process with any therapy, especially alternative, start with the patient's believing that this process will work? How do you get past that part?
Dr_Joseph: That's true and that even includes biomedical medicine. I have seen patients not respond to pain killers because they believed they wouldn't work. When we make recommendations to patients for what we think is going to be beneficial for them, we have them decide which of those therapies they feel is going to be beneficial for them. That's the main way we get beyond their belief system. Other than that, you can have the patient try therapies for limited periods of time and make up their own mind whether they think those therapies will be beneficial or not.
Dr_Zeltzer: I also think that education can be an important component to helping someone shift their belief system. For example, patients who come to us with chronic pain may have been told by their physician or subspecialty physicians whom they saw first that there is "no reason found for their pain". This leaves the individual feeling like either the doctor is an idiot or the doctor believes that it's all in my head, it's psychological or I'm making it up. Part of our first job is to explain to patients in a brief way about the physiology of pain medicine. And how a lot of chronic pain may have started from some acute illness, inflammation, or injury that has long healed. So, for example, if a gastroenterologist performs an endoscopy, that is, a tube down the esophagus into the stomach to look for causes of severe belly pain, the stomach may look perfectly normal. However, with most chronic pain, the problem relates to nerve signaling. If we had an electrical engineer who could look at the signals and wiring system of the body, we would likely be able to see which wires are not working well. So by changing the belief system of the individual to see chronic pain as a nerve signaling disorder, that can lead to a lot of other factors that can add to the pain or keep it going such as holding the body in a certain way to protect it, leading to muscle pain on top of the original pain. Then the treatments such as acupuncture, medication, biofeedback all make sense with the goal of getting the body's own pain control system working well again. In other words, getting the body back in balance.
sousan_WebMD: [question presented] How do you get your doctor to try alternative therapies and stop just switching drugs?
Dr_Joseph: Unfortunately, most of what doctors have been trained in is the use of medications or surgery if they're a surgeon. Their decision is based on what they know and feel comfortable with. Giving them the opportunity to learn about alternative therapies by recommending that they speak with a therapist that you have identified may go a long way to helping them feel more comfortable and increasing their knowledge base so that they can then refer you, as well as future patients to complementary medicine therapists.
Dr_Zeltzer: Some physicians feel worried about recommending therapies that have not been scientifically proven. And providing some literature by doing even an Internet search on the topic or the kind of therapy can be very useful for coming up with articles from scientific journals that show studies on these therapies. This can be one way of influencing a physician whom you otherwise trust. So patients need to be advocates for broadening the experiences and beliefs of their physicians.
Twosteprva_WebMD: [question presented] I can't take meds for pain. What can I do?
Dr_Joseph: There are a lot of complementary medicine techniques that could potentially be very helpful. The ones that come immediately to mind and the ones that we use in our clinic include: acupuncture, biofeedback, massage, movement therapy, bioenergy healing, psychotherapy, cognitive behavioral therapy, physical therapy, yoga and meditation. We often treat patients without the use of medications.
Event_Moderator: [question presented] As we go into the new millennium, do you see the future of medicine involving alternative therapies more or will it always be on the fringe?
Dr_Joseph: No. I truly believe that the use of complementary medicine techniques will become more and more mainstream. Again it will be not an issue of complementary versus biomedical, but again good medicine versus bad medicine and that we will begin to use all therapies that can be beneficial for our patients.
Dr_Zeltzer: As evidence of what Dr. Joseph just said, the National Institutes of Health in Washington, D.C. has established an office of Alternative and Complementary Medicine. The purpose of this special office is to oversee the research in these alternative and complementary therapies. Increasing amounts of funding are being directed toward testing these therapies so as Dr. Joseph said, more and more of these will become mainstream.
Event_Moderator: [question presented] Why are people, especially Americans, so resistant to what are really ancient forms of healing?
Dr_Joseph: Both Dr. Zeltzer and I believe that people are not resistant but the biomedical industry and physicians are resistant. Change is somewhat scary. I think that the recent change has come out of people feeling that biomedical medicine is not addressing all of their health needs. It's not a holistic approach to health. The fact that many people in our culture still rely on medications comes from that's what is culturally appropriate. That will change over time. There are interesting trends also within the more ancient cultures in China and Japan turning towards biomedical medicine and turning towards medication for their therapies and turning away from their traditional forms at the same time. What I see globally is that we won't be moving closer to them or them closer to us but we will all be moving closer to the center.
Event_Moderator [question presented] A startling number of prescriptions for painkillers are written every year. Why do we need to medicate ourselves so much?
Dr_Joseph: It's sort of a difficult answer on two sides. One, I think that we are overmedicating ourselves because that is the biomedical answer to chronic pain. There are only so many ways that physicians know to treat pain. That has made us reliant on pain medications. There are many other techniques that we've already discussed in this program that can be implemented that are non drug based and should be implemented more and more in the future. In addition, part of our culture, being a culture of consumerism and advertising, has definitely put forward the use of pain medications to cure anything that ails you.
Dr_Zeltzer: The goal of treating chronic pain is to help the body do what it does naturally in terms of pain signaling, pain transmission, that is, from pain to brain and pain control...from brain to pain. Alternative and complementary therapies, whatever type, all have the common goal of helping restore the body's homeostasis or balance...so that the body's own functions can act naturally. No matter what type of philosophy or system such as traditional Chinese medicine or Ayervedic, from India, the ways of explaining health and illness or symptoms such as chronic pain I believe are metaphors for the concept of the body being out of balance. So the goals of all of these treatments are to help the body do what it used to do before and what it can do again, after the chronic pain resolves.
Event_Moderator: Dr. Joseph and Dr. Zeltzer, thank you both for joining us.
Dr_Zeltzer: Thank you.
Dr_Joseph: Thank you. 
By Lauran Neergaard
The Associated Press
December 25/00Washington, D.C.- When you enter a hospital, you have a right to have your pain properly treated.
That sounds so common-sense, yet millions of Americans suffer every day because pain is routinely ignored or undertreated.
But starting next week, the nation's hospitals must make a major change: New standards require that every patient's pain be measured regularly from the time they check in - just like other vital signs are measured - and proper pain relief begun or the hospitals risk losing their accreditation.
Patients should expect at least to be asked to rate how they're feeling, from zero, no pain, to 10, the worst pain imaginable. (Small children will use pictures to rate pain.) The score determines what steps the hospital must take to help.
To stress how important the changes are, the new standards actually put in writing that "patients have the right'' to proper pain assessment and treatment.
Some hospitals already are handing out leaflets and posting signs in the halls telling patients about that right, so they know it's OK - nay, crucial - - to complain if a doctor or nurse doesn't help.
Better, it's not just hospitals that must take the new steps but nursing homes and outpatient clinics accredited by the Joint Commission on Accreditation of Healthcare Organizations. The commission adopted the standards over a year ago, but gave facilities until January to comply.
It's "a watershed event,'' said Dr. Russell Portenoy, pain medicine chairman of New York's Beth Israel Medical Center. "No one has ever promised patients no pain. But what JCAHO wants to do is promise people their pain will be assessed and managed in a state-of-the-art way.''
Many centers still are scrambling to comply. Teaching health workers who aren't pain specialists how to treat can take some time - and many doctors inappropriately shun narcotics, a treatment mainstay for numerous types of pain, because they think patients will get hooked on them.
"This is not going to happen overnight,'' cautioned American Pain Society president-elect Christine Miaskowski, nursing chair at the University of California, San Francisco.
"Patients are going to have to demand better care, "she said. "Unrelieved pain has negative effects. Just like they need an antibiotic to treat infection, they need analgesics to treat their pain.''
But many patients don't know they don't have to suffer - or that pain is more than bothersome, it actually hinders healing.
So being a stoic isn't good. Revealing how much pain you're in doesn't "bother the doctors'' or distract them from treating your underlying disease, common excuses. "People think it's like an 11th commandment: "Thou had surgery, thou should have pain." ... Or that if you have cancer, you must have pain," said June Dahl, a University of Wisconsin pain specialist who helped write the standards. "Pain can be relieved."
How big is the problem? Cancer provides the best estimates: About 40 percent of cancer patients have under-treated pain. One in four elderly cancer patients in nursing homes receives no treatment at all for daily pain. Last year, Oregon's medical board disciplined a doctor for treating a dying cancer patient's pain with mere Tylenol.
Look beyond hospitals and some 9 percent of Americans suffer chronic pain, ranging from back injuries to rheumatoid arthritis. Experts say four of every 10 with moderate to severe pain don't get adequate relief.
One of the biggest challenges is teaching nonspecialists that narcotic painkillers called opioids - such as morphine, codeine, fentanyl - are the mainstay for many types of pain, Portenoy says.
Many doctors hesitate to prescribe opioids, which are heavily regulated because they can be abused by addicts. But for people who have never abused drugs and have no history of psychological problems, hardly any become dependent on pain medicine, Miaskowski said.
Another complaint, heavy sedation, usually wanes in three to four days, she said.
So what's state-of-the-art treatment? For moderate to severe pain from acute illness or surgery, expect a short-acting opioid like Percocet, or morphine in a patient-controlled quick-dose pump. For cancer, expect a long-acting version of morphine or oxycodone, or a fentanyl skin patch.
For chronic pain not due to cancer, new guidelines recommend similar opioids.
Methadone is an alternative when those drugs fail.
Doctors also are trying antidepressants and antiseizure drugs like gabapentin for patients with nerve-related pain.
And relaxation helps, too - but shouldn't replace proper medication, Miaskowski stresses.
Editor's Note: Lauran Neergaard covers health and medical issues for The Associated Press in Washington.
New National Standards for Pain Management SetBy John McKenzie
ABC News
January 2/01
More than 50 million Americans suffer from chronic pain, according to the American Pain Foundation. And thus far, managing pain has not been a high enough priority for many doctors and medical institutions.
But a new set of national standards aims to change that. Starting this week, health-care centers around the country are required to begin screening every patient for their pain levels, and have them measured and recorded. Patients may be asked to rank their pain intensity on a scale of zero to 10, with zero meaning no pain, and 10 meaning unbearable pain. Health-care centers will then have to decide on therapies to relieve the pain, and document the results.
"Patients have the right to effective assessment and management pain, and that's the standard that all health facilities must adhere to," says June Dahl, a professor at the University of Wisconsin medical school who helped write the new standards.
Proper Treatment of Pain Important:
Until now, there have been no national standards for the management of pain. Studies of cancer patients have suggested that about 40 percent receive inadequate pain medication. Often, they're given nothing more than aspirin or Tylenol. And among the post-surgery patients, studies have suggested about 50 percent receive inadequate pain relief.
Proper treatment of pain is important not only because it allows patients to feel better, but also because it may help speed their recovery. After surgery, patients with less pain are able to breathe more deeply, walk more easily, and leave the hospital more quickly.
The new standards, which were issued by the Joint Commission on Accreditation of Healthcare Organizations require that hospitals and nursing homes ensure their staff knows how to treat pain effectively, and also asks that patients and their families know how to manage it. Thus far, many health-care centers are still scrambling to implement the standards. Those that do not risk losing their accreditation as well as their federal funds from Medicare and Medicaid.
"No health-care professional can promise a patient that he or she won't feel any pain," says Dr. Russell Portenoy of the Beth-Israel Medical Center in New York. "But we can promise that a patient's pain will be take seriously, it will be assessed, and it will be managed in a state-of-the-art way."
Various Options Available:
In some cases, that might mean using more powerful medications like morphine and codeine. If patients have no history of substance abuse, studies show there is virtually no risk of addiction. There are also plenty of non-traditional pain therapies, including acupuncture, meditation, physical therapy, and massage.
"[There are] various techniques that one can apply to a specific pain problem," says Dahl. "The important thing is to match the choice of therapy with the intensity and type of pain the patient is experiencing."
Many patients consider pain a natural, unavoidable consequence of sickness or surgery. Health-care centers are now being required to prove them wrong.