Blending Prescription Pain Treatments with Alternative Medicine
The practice of pain management in recent years has emerged along various tracks. Anti-inflammatory agents, opioids, and other prescription medications and devices have been the mainstay of the physician. Simultaneously, a variety of treatments with non-prescription procedures and chemicals have become very popular with the public.1-4 Advertisements, websites, and publications abound with many supportive reports of welcome pain relief with measures that are commonly called alternative or complementary. Physicians are often criticized for prescribing drugs for pain rather than using alternative treatments. In reality, however, almost all physicians who treat pain routinely recommend non-prescription measures in addition to their prescription treatment regimen. In addition, ambulatory patients who don’t have an acute emergency don’t complain to a physician until they have unsuccessfully attempted some non-prescription measures.1,2
This article is written to clarify some of the terminology and provide definitions to better understand the totality of the alternative pain movement. It is recognized that the aegis of much of this movement is profit without the benefit of controlled studies.2-4 Nevertheless, persons in pain want relief that is convenient, inexpensive, and easy to access with the least use of prescription medications and procedures that always carry at least some minimal, inherent risk. It is my belief and experience that some of the emerging, non-prescription measures are worth recommending to patients. While not always a substitute for prescription drugs, some non-prescription measures may enhance or complement a physician’s pain treatment.3-6 A brief description of most alternative treatments is given here along with some case examples. The term ‘blended’ is used to illustrate the point that opioids and other prescription measures such as a TENS (transdermal electrical nerve stimulation) can be blended or used in a complementary way with many non-prescription measures to enhance patient care.
Definition and Fallacy of the Term ‘Alternative’
The term ‘alternative’ simply means ‘non-prescription’ (see Table 1). Physicians must be aware that this term is often misleading and sometimes used in a pejorative sense to criticize the practicing physician. While most alternative medicine measures have few evidence-based, controlled studies, or specific indication approved by the U.S. Food and Drug Administration, many appear anecdotally to be clinically effective, inexpensive, and popular with patients.5,6 However, the number of studies involving non-prescription methods and agents are growing and are reported in publications that are often more familiar to patients than physicians.
It is somewhat misleading to state that alternative treatments are not regulated by the US Food and Drug Administration (FDA). While a product may not be labeled or advertised as a treatment for pain, they may still be regulated. Many alternative treatments are regulated under the FDA “Dietary Supplement Act” or regulations which govern the formulation of topical or skin cream agents. For example, an oral tablet, powder, or capsule must list the amount of amino acids, vitamins, minerals, and other nutrients and a skin cream marketed for pain relief must list its active ingredients such as menthol or salicylic acid.
The fallacy of the term ‘alternative’ is that it may imply or insinuate that an agent is an effective substitute for prescription drugs. This may or may not be the case. Prescription drugs and many devices such as TENS are prescription because the FDA well-recognizes that there may be some risk in their use. To be approved as a prescription medication or device, a commercial company will have to conduct some controlled clinical trials and studies to establish efficacy, safety, and risk determination. Most of the treatments known as alternative have not demonstrated efficacy although they may not carry any significant risk.5,6
Due to their non-prescription status, physicians can recommend any number of alternative treatments to complement or enhance prescription treatments.3,4 Some terms now used to describe this process are complementary or “integrative.” Both are appropriate and I use the term ‘blended’ to illustrate that prescription and non-prescription approaches can and should be simultaneously recommended to patients. Often, commercial producers and practitioners of alternative medication use the terms restorative and reparative rather than the term ‘treatment.’ Table 1 provides some simple definitions to establish terminology that I recommend be adopted so all parties can be clear about the growing use of non-prescription agents.1,2
Cautions and Admonitions
The caution and admonition to physicians and the public is that alternative does not mean “substitute,” and that severe forms of chronic pain that exhibit physical and mental impairment of the activities of daily living and/or demonstrate biologic changes such as hypertension, tachycardia, insomnia, anorexia, attention deficit, or hormone alterations will unlikely respond adequately to non-prescription measures. Patients and the public are done a disservice when any party pushes or advertises non-prescription pain treatments without warning the receivers of these treatments that chronic pain covers a spectrum of severity, and that the severe forms may carry serious, life impairing and shortening consequences if prescription measures are not sought and obtained.
Common Non-Prescription Treatments
Most of the popular alternative or non-prescription treatments which have emerged in recent years are summarized in Table 2. Some are briefly described and some case examples are presented to illustrate the blending or complementary use of prescription and non-prescription measures (see Table 3).
The Placebo Factor
Few alternative treatments have placebo-controlled, random studies to validate their effectiveness.3-6 Consequently, the physician who recommends them must recognize that the treatment may have only anecdotal reports or reports from his/her own patient to support the treatment. Nevertheless, keep in mind that a “placebo effect” does access neuropathways that induce a positive message to the immune system.