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Integrative Pain Care: When and How to Prescribe?

In this Q&A, Robert Alan Bonakdar, MD, director of pain management at Scripps Center for Integrative Medicine in San Diego, California, discusses proven alternative pain management techniques for pain conditions including the lower back, migraines, and osteoarthritis.
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The practice of integrative pain management is designed to enhance current treatment models by incorporating a range of nonpharmacological modalities, from acupuncture and massage to mindfulness and yoga, into the routine care of pain patients with the goal of lessening pain and improving function and quality of life. Practical Pain Management spoke with Robert Alan Bonakdar, MD, director of pain management at the Scripps Center for Integrative Medicine in San Diego, California, about which integrative pain practices have shown the greatest efficacy in evidence-based studies for a variety of conditions, specifically chronic low back pain, neuropathic pain, postsurgical pain, osteoarthritis, headache, and fibromyalgia.

Integrative pain therapy modelAn integrative pain therapy model.

What integrative practices for pain offer the greatest efficacy in evidence-based studies?

Research on integrative pain care has evolved at a rapid pace over the past five to 10 years. We have seen a number of influential studies published on yoga, acupuncture, and mindfulness-based stress reduction (MBSR) that have added to our knowledge of effective nonpharmacologic treatments for pain, including massage and Tai-chi. The American College of Physicians’ clinical practice guideline outlines which of these integrative therapies are strongly recommended as initial treatment for chronic low back pain (see Table 1).1

Noninvasive treatments for chronic low back painNoninvasive treatments for chronic low back pain.

For neuropathic pain, the research on acupuncture, especially electroacupuncture, has been impressive, showing improvement in nerve conduction in several studies.2-4 Research also is emerging on the role of cannabinoids in reducing neuropathic pain.5,6

For postsurgical pain, a recent meta-analysis of randomized clinical trials (RCTs) presented moderate-certainty evidence that acupuncture and electrical stimulation significantly reduced and delayed opioid consumption after total knee arthroplasty.7 Given the new mandate from the Joint Commission on Accreditation of Healthcare Organizations for the use of nonpharmacological approaches enhance in-patient pain assessment and management, I believe there will be an accelerated effort to incorporate these options into pain practices.8

Findings from the 18-month Intensive Diet and Exercise for Arthritis (IDEA) trial that showed a supervised diet and exercise program had a significantly greater effect on improving pain and function in knee arthritis than exercise alone.9 It is clear that for osteoarthritis, the role of diet and exercise is indispensable.

Although the value of nutritional supplementation has been confusing because of the sheer number of options on the market, use of the following medical-grade supplements have demonstrated efficacy in clinical trials:

  • Chondroitin: Chondroitin sulfate 800 mg/day was as effective as celecoxib and superior to placebo (P = 0.001) in a prospective RCT of 604 patients with symptomatic knee osteoarthritis.10
  • Turmeric: A meta-analysis of RCTs supported the efficacy of turmeric extract (approximately 1,000 mg/day of curcumin) in the treatment of arthritis. Trials with turmeric/curcumin showed a significant reduction in pain visual analogue score (PVAS) in three studies (mean difference vs placebo: -2.04; P < 0.00001), decreased Western Ontario and McMaster Universities Osteoarthritis Index in 4 studies (mean difference vs placebo: -15.36; P = 0.009), and no significant mean difference in PVAS between turmeric/curcumin and pain medicine in five studies.11

One of the most underutilized
evidence-based tools for management of migraine disorders, including chronic daily headache, and fibromyalgia is biofeedback. This approach appears beneficial in reducing pain amplification by training patients to modulate autonomic dysfunction, including sympathetic overdrive.12-14

Additionally, a number of nutrients—based on correcting a deficiency, providing mitochondrial support, or reducing oxidative stress—appear to improve headache and fibromyalgia pain:

  • Acetyl L-carnitine: This nutrient helps with the conversion of fatty acids into energy. In a RCT comparison of acetyl L-carnitine (1,500 mg/day) to duloxetine (60 mg/day), the nutrient showed positive (nonsignificant) effects on fibromyalgia pain and a significant improvement in depression (P < 0.001) and overall clinical improvement (P < 0.001).15
  • Coenzyme Q10 (CoQ10): Patients with fibromyalgia typically have significantly depressed CoQ10 levels, which is involved in energy production, compared to controls.16 CoQ10 supplementation at 300 mg/day has been shown to restore biochemical parameters and significantly reduce fibromyalgia impact based on the Fibromyalgia Impact Questionnaire, pain level, and related headache (P < 0.001 for all comparisons).16
  • Melatonin: Individuals who took 3 mg of melatonin at bedtime significantly reduced headache frequency compared with placebo (P = 0.009), and it appeared as effective as amitriptyline 25 mg (P = 0.19) but with improved tolerability. Responder rates (>50% reduction in headache frequency) were significantly greater among those taking melatonin than amitriptyline (54.4% vs. 39.1%; P < 0.05).17

Data on these research studies and how to incorporate integrative medicine into pain practices will be featured at the October 2017 Academy of Integrative Pain Management conference (see Resources).

Integrative pain management resourcesIntegrative pain management resources.

Continue Reading:
United Nations Says Untreated Pain Is “Inhumane and Cruel”
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