We are in the midst of an opiate epidemic with horrific numbers of overdoses, suicides and ruined lives. More people die daily in the U.S. from these painkillers than from auto accidents. This is part of the reason that medical treatments are the third leading cause of death in our country.
A slippery road with many forks awaits clinicians in this area. What seems like a compassionate endeavor to relieve unrelenting pain, say from an arthritic condition, can lead to overtreatment, side effects, falls, cognitive impairment, family and relational issues, work or sleep problems, depression, anxiety and addiction.
Let me share one story that illustrates the problem. Monica is 86 years old, and has been under my care for 20 years. She retired from her work at the University of Texas Medical Branch in the occupational therapy field, an area in which she had made substantial contributions both as a faculty member and health care provider. Despite remaining active in her personal fitness program, adhering to a healthy diet, and doing tai chi regularly, she was increasingly impaired by arthritis pain in her knees and back.
After falling a couple times, her pain became unbearable. Physical therapy and short-term opiates were provided to get her through the acute phase. However, she gradually came to need her opiates daily. They gave her constipation and mood changes. Her son was concerned they were impairing her memory and balance. We tried non-opiate medications, aquatherapy, more tai chi, massage, acupuncture and other methods with partial benefit.
Her cognitive function continued to decrease and she had more falls. We had to wean her off narcotic pain medicines completely. She learned to cope with her pain with activity, herbal and nutritional supplements, some home physical therapy, and occasional acetaminophen. Guess what? Her mood and cognition improved and her recurrent falls stopped. This was a win-win, though things do not always play out this nicely.
I recently attended a meeting, the Academic Consortium for Integrative Medicine and Health, a group of 72 academic centers and health systems. A major international initiative is underway by a dedicated task force to improve non-pharmacologic treatment of pain. They are summarizing the best research evidence, creating a white paper, and developing clinical and educational guidelines for multiple pain conditions faced by patients, practicing physicians and health care trainees. They also are addressing policy and insurance issues to improve reimbursement for non-pharmacologic therapies.
Momentum is building as multiple stakeholders direct their efforts to this problem. The Veterans Affairs health system, pushed by heavy human and financial costs from addiction, depression, suicide and post-traumatic stress disorder in their recovering veterans has increasingly adopted non-pharmacological therapies. Their division of integrative medicine supports programs to treat veterans without drugs using mindfulness training, cognitive behavioral methods, group sessions, acupuncture and other methods.
The American College of Physicians recently recommended non-pharmacological management of pain as the preferred initial approach. The Joint Commission on Hospital Accreditation now requires that hospitals offer non-pharmacological approaches to pain.
These may include patient education, exercise, heat/cold application, osteopathic manipulation therapy, chiropractic, massage, acupuncture, yoga, tai chi, behavioral therapy, mind-body approaches, music therapy, aromatherapy, Reiki and healing touch.
Recall always the Hippocrates’ dictum, “Primum non nocere” or “First, do no harm.”