Acupuncture: a Non- Opioid Treatment for Pain

Transcription

1 Acupuncture: a Non- Opioid Treatment for Pain September 28, 2018 St. Charles Health System Disclosures This presentation does not contain proprietary information on the practice of acupuncture Dr. Tanuja Goulet, LAc, DAOM Licensed Acupuncturist, Doctor of Acupuncture and Oriental Medicine No relevant financial relationships exist Overview Training and Certification Classical Text Opioid Crisis Acupuncture Research Coordination of Treatment A good sign your acupuncturist might be getting bored with the job.

2 Training & Certification Bachelor s in Biochemistry, Barnard College, Columbia University Doctorate in Oriental Medicine, and Master s in Oriental Medicine Is Tanuja an Acupuncturist? Oregon College of Oriental Medicine National Certification in Acupuncture and Chinese Herbal Medicine Oriental Medicine Acupuncture St. Charles Team Nursing/Surgery/Patient Consultations/ Lab/Behavioral health Yellow Emperor s Canon of Internal Medicine, written approx. 300BCE Question Chinese Herbal Medicine Tai Ji, Qi Gong, Movement-Meditation, Asian Bodywork Dietary advice Nourish life Pharmaceutical PT/OT/Exerise Nutrition Caring Attitude I am told the people in ancient times could all survive to more than one hundred years old, and they appeared to be quite healthy and strong in actions, but the people at present time are different, they are not so nimble in actions when they are only fifty, and what is the reason? Is it due to the change of spiritual principles or caused by the artificial behavior of men?

3 Yellow Emperor s Canon of Internal Medicine, written approx. 300BCE What is Acupuncture? Answer They forgot how to live a moderate life based on natural rhythms and conserving energy Macro to Micro Case Study Acupuncture is 38 yo, Female, muscle spasms for 1.5 years Inserting very fine filiform needles Pain 5 8 out of 10, low Bulging disc Treatments so far: back and abdominal and spine arthritis Chiropractic spasms for hours at a time, hot flashes, sweaty PT Medications Baclofen 20mg 3x daily Tramadol 50mg 2x daily Gabapentin 200mg 3x daily, then 300mg at night Carisoprodol 350mg 2x daily as needed Duloxetine 20mg 2x daily Tylenol PM Meloxicam 15mg in the morning CBD tincture into the skin, connective tissue, and muscle Inserting the needles at specific points

4 Acupuncture is Using Chinese medicine theory and diagnostics (pulse, tongue) to locate points and choose point combinations Generally safe Acupuncture Safety Study 9,408 patients baseline data 6,348 patients completed 3 month data from >30,000 treatment visits SAE: 3 (5 per 10,000 treatments) AE 682 patients 10.7% in 3 month period *SAE: serious adverse events **AE: adverse events minor, often self-limiting side effects MacPherson et al (2004) Quality & Safety in Healthcare 13, Acupuncture Safety Study Opioids Side Effects Patient Reported Tiredness 227/6348 Prolonged pain at site of needling 103/6348 Needle left in 55/6348 Bruising at needle site 33/6348 Pneumothorax 0/6348 Serious 3/6348 Codeine Fentanyl Hydrocodone Hydrocodone/Acetaminophen Hydromorphone Meperidine Methadone Oxycodone Oxycodone & Acetaminophen Oxycodone & Naloxone Buprenorphine Butorphanol Oxymorphone Tapentadol MacPherson et al (2004) Quality & Safety in Healthcare 13, Morphine Tramadol

5 National Opioid Epidemic Oregon Deaths from Opioid Epidemic ,000 52,898 33,000 Deaths from Acupuncture Treatment Local Oregon By tomorrow morning, more than 100 Americans will have died because of opioid overdose. This killer doesn t discriminate not by age, not by race, not by where you live or what you believe. In Oregon, 506 people died from opioid overdoses in 2016 more than in traffic accidents. Oregon November 2015 Oregon Health Authority guideline, Oregon Prescription Drug Overdose Misuse and Dependency Prevention Plan This document supports increase in access to non-opioid treatments for pain United State Representative Greg Walden Bend Bulletin, June 22,

6 Oregon 2016 Oregon Opioid Prescribing Guidelines Task Force approved the CDC Guideline for Prescribing Opioids for Chronic Pain Need for more knowledge about non-opioid treatments What have you heard about acupuncture research? Research Study Design What are we studying? RCTs gold standard Systematic reviews Case studies, case series Effectiveness VS Efficacy Clinical outcomes studies The Gold Standard

7 RCT Design Acupuncture vs. Sham Acupuncture (many non-acupuncture methods devised for RCTs) Acupuncture at acupoints vs. Acupuncture at non-acupoints Acupuncture vs. Usual Care (biomedical) Acupuncture vs. Massage Primary and Secondary Outcomes Outcomes Study on Acupuncture Effect South Carolina HIV and peripheral neuropathy Group acupuncture, 5 weeks, individualized Twice a week 21 subjects Pre- and post-treatment Pain Rating Scale and Subjective Peripheral Neuropathy Screen The Journal of Alternative and Complementary Medicine.Jun ahead of print. Pre- and Post-treatment Pre- and Post-treatment The Journal of Alternative and Complementary Medicine. Jun Ahead of print. The Journal of Alternative and Complementary Medicine. Jun Ahead of print.

8 Low Back Pain in Adults Study Washington Primary Outcomes Disability Scores 4 arm RCT, individualized acupuncture, standardized acupuncture, simulated acupuncture, usual care n= treatments in seven week treatment time; Twice a week at first Primary Outcome : Pain Secondary Outcome : Quality of Life - 52 weeks Arch Intern Med May 11; 169(9): doi: /archinternmed Arch Intern Med May 11; 169(9): doi: /archinternmed Secondary Outcomes Bothersomeness Secondary Outcomes Fewer medications More active Missed fewer days of work or school Arch Intern Med May 11; 169(9): doi: /archinternmed Arch Intern Med May 11; 169(9): doi: /archinternmed

9 Low Back Pain England 2 arm RCT acupuncture vs. usual care n=241 adults 10 treatments short course Secondary Outcomes 24 Months Fewer medications Less pain Less worry about the low back pain 3 months treatment time BMJ, doi: /bmj c (published 15 September 2006) BMJ 2006; 333 doi: (Published 21 September 2006) Sleep as Secondary Outcome Sleep as a QOL outcome in RCTs of acupuncture for: Back pain (5) Menopausal hot flashes (8) Breast cancer (5) Cancer (6) Psychiatric population (1) Fibromyalgia (2) Medical students (2) Prospective Randomized Trial on Emergency Room Patients Tunisia n=300 Moderate to severe acute onset pain 150 acupuncture, 150 morphine Primary outcome: pain relief ( 50% reduced pain) acutrials.ocom.edu Am J Emerg Med Nov;34(11): doi: /j.ajem Epub 2016 Jul 20.

10 Prospective Randomized Trial on Emergency Room Patients Tunisia Success: Acupuncture 92% vs. Morphine 78% (P<.001) Resolution time: Acupuncture 16±8 minutes vs. Morphine 28±14 minutes (P<0.005) VA: Retrospective Chart Review 172 patients, 4 acupuncture treatments in past year Conditions included: Back pain Knee pain Neck pain Headache Anxiety Insomnia Mean age 43, range 18 73, F 103/M 69 Minor adverse effects 29.6% patients (89 patients), 85 morphine/4 acupuncture (P<0.001) No major adverse effects Am J Emerg Med Nov;34(11): doi: /j.ajem Epub 2016 Jul 20. Medical Acupuncture Volume 29, Number 4, 2017 # Mary Ann Liebert, Inc. DOI: /acu VA: Retrospective Chart Review Medication decrease: Opioid 45% Muscle relaxant 34% NSAID 42% Benzodiazepine 14% Comparing pre-treatment and 1-year follow up Statistically improved: Well-being Life function Symptom control Acupuncture Benefits Improved QOL Patient satisfaction with care Low risk, not addictive Less pain Long-lasting results Medical Acupuncture Volume 29, Number 4, 2017 # Mary Ann Liebert, Inc. DOI: /acu

11 Pain conditions that require referral Acute abdomen Acute trauma such as loss of consciousness Initial stages of stroke, heart attack, severe burns Sudden onset of neurological conditions Brain tumor Cauda equina syndrome Pain conditions that require referral Other cases when physical solutions are required, e.g. gastric device has moved out of position Non-emergency pain that is not responding to acupuncture within 3 5 treatments, e.g. they feel better during treatment but not afterward, then they should be referred for further evaluation Acupuncture not Advil (or Opioids) Partial List Patients who get best results Trauma history: auto accident, domestic abuse Repetitive strain Migraine or tension headache Menstrual pain Spasm in waves moving through the body Radicular pain Knee pain Dental pain/tmj Back pain Inconclusive X-ray or MRI with spasm, tremor, or pain Emotional state reflects pain Menstrual pain, heavy bleeding, and menstrual-related emotions Stress affecting patient health

12 Case Study 38 yo, Female, muscle spasms for 1.5 years Case Study 38 yo, Female, muscle spasms for 1.5 years Pain 5 8 out of 10, low back and abdominal spasms for hours at a time, hot flashes, sweaty Baclofen 20mg 3x daily Gabapentin 200mg 3x daily, then 300mg at night Duloxetine 20mg 2x daily Bulging disc Meloxicam 15mg in the morning and spine arthritis Tramadol 50mg 2x daily Carisoprodol 350mg 2x daily as needed Tylenol PM CBD tincture Treatments so far: Chiropractic PT Medications Results after Acupuncture - 4 Treatments Able to work three full, eight-hour days. Getting a few sharp kicks, but relaxes throughout the day. Spasming 5 6 per day this is good! Able to reduce medications with her internal medicine doctor Results after Acupuncture - 7 Treatments 2 months on, she is able to attend family functions, 4 days a week work, strong spasms 2x per week Acupuncture is Cost-effective Treatment Coordination Course of treatment with $25 copay Acupuncture Prescription drug $300 $300 Time investment get life back feel dull and drowsy Insurance St. Charles Health System Providence Regence Cigna Non-insurance price (course of tx) $1000-$2000 $300 evaluation plus drug cost Oregon Health Plan VA Illegal purchase n/a $80/day, including loss of life PacificSource Addiction rehab n/a $$$, relapse common

13 Treatment Coordination Community or sliding-scale acupuncture Hawthorn Healing Arts Bend Community Healing Bend Community Acupuncture Treatment Coordination Refer to acupuncturists Recommend treatments with acupuncture Support patients in taking Chinese herbal medicine, in positive change of lifestyle, diet, exercise Experience treatment yourself Speaking to Patients/Family Gratitude To Improve care coordination: you and your friends and family need to experience acupuncture. I have my own issues too If you were my wife/daughter I would want you to I go to acupuncture for my neck pain, because I sit at this computer all day long. This is a stressful profession, acupuncture helps me to handle it much better. Alzada Magdalena, Licensed Acupuncturist Steven Foster-Wexler, Licensed Acupuncturist Continuing Medical Education, St. Charles Health System Scott Arany, Graphic Designer

14 Contact Tanuja Goulet Tanuja Goulet Doctor of Acupuncture and Oriental Medicine, Licensed Acupuncturist tanujagoulet.com Question 1 In the USA study of acupuncture for low back pain, at how many weeks of acupuncture did patients report sustained pain relief? A) 2 weeks B) 14 weeks C) 7 weeks (541) Question 1 Question 2 In the USA study of acupuncture for low back pain, at how many weeks of acupuncture did patients report sustained pain relief? A) 2 weeks B) 14 weeks C) 7 weeks Which of the following are secondary outcomes from the USA RCT of low back pain? A) Less worry about pain B) Less pain C) Fewer medications D) All of the above

15 Question 2 Which of the following are secondary outcomes from the USA RCT of low back pain? A) Less worry about pain B) Less pain C) Fewer medications D) All of the above Question 3 Acupuncture is NOT recommended for which of the following: A) Cauda equina syndrome acute phase B) Acute phase of stroke or heart attack C) Medical device has moved out-of-place D) Pain conditions that are not responding to acupuncture after 3 5 treatments E) All of the above Question 3 Question 4 Acupuncture is NOT recommended for which of the following: A) Cauda equina syndrome acute phase B) Acute phase of stroke or heart attack A VA Retrospective chart review found that patients receiving at least four acupuncture treatments in the past year were reducing which medications by more than 40%? C) Medical device has moved out-of-place D) Pain conditions that are not responding to acupuncture after 3 5 treatments E) All of the above A) Opioid B) Metformin C) Benzodiazepine D) NSAID

16 Question 4 A VA Retrospective chart review found that patients receiving at least four acupuncture treatments in the past year were reducing which medications by more than 40%? Question 5 What should you tell your colleague who has knee pain? A) You re a wimp, come on a bike ride tomorrow. B) I looked up your X-rays in EPIC and they look terrible. A) Opioid B) Metformin C) Benzodiazepine D) NSAID C) My son went for acupuncture and his PT said that his ACL recovery was smoother than he expected. D) I go for acupuncture and now I have less neck pain when I m doing my EPIC charting. Question 5 THANK YOU What should you tell your colleague who has knee pain? A) You re a wimp, come on a bike ride tomorrow. B) I looked up your X-rays in EPIC and they look terrible. C) My son went for acupuncture and his PT said that his ACL recovery was smoother than he expected. D) I go for acupuncture and now I have less neck pain when I m doing my EPIC charting.