8/17/2018. Overview. I. Introduction of IM & review impact(s) on Health. An Integrative Approach to Pain Management. Saturday, August 11, 2018

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1 An Integrative Approach to Pain Management Saturday, August 11, 2018 Erika Cappelluti, MD, PhD, MA, FCCP, ABOIM, ABIHM Medical Director Integrative Medicine Hartford Healthcare Cancer Institute Fellowship Director AIHM Fellowship Program Overview I. Introduction, What is Integrative Medicine? II. Review & discussion of clinical research Consortium WHITE PAPER III. Integrative Medicine at Hartford Hospital & the Future of Integrative Education I. Introduction of IM & review impact(s) on Health. ACIMH on IM: IM and health reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing. A) Types of IM 1) Natural Products: herbal medicines, botanicals, dietary supplements 2) Mind and Body Medicine: acupuncture, meditation, yoga, qi gong, tai chi 3) Manipulative and Body-Based Practices: massage chiropractic, osteopathic B) Whole medical systems: Ayurveda, Traditional Chinese homeopathic and naturopathic Medicine Others: movement therapies- Pilates, Feldenkrais method, Alexander technique, therapeutic touch, Native American healer/medicine woman 1

2 I. Introduction of IM Terminology CAM: Complementary and alternative medicine Therapies that are non-conventional that are used in conjunction with conventional or as an alternative to conventional medical modalities. CIM: Complementary and integrative medicine Derives from the growing body of literature which has shown that many CAM therapies are effective when used in conjunction with conventional care. CIM reflects the fact that evidence based CAM therapies are increasingly being incorporated into conventional care. IM in the United States 40-60% of adults and ~15% of children use IM 2007 out-of-pocket expenditure =$34 billion. ~12% of all out-of-pocket expenditures for health care in U.S. Also, IM visits exceeded those for primary care 80-90% Cancer patients use IM National Health Statistics Reports.No18;July 30, 2009 > 40 % is related to pain 2

3 Publications in PubMed ~10yr Hx Herbal Therapies for Treating Pain Out-of-pocket Spending on IM by Adults in United States Reported 2009 National Health Statistics Reports.No18;July 30,

4 Adverse Effects Associated with Chronic Pain Diet Supplements Mood (+) Acupuncture, manual therapy Depiction of the adverse effects associated with chronic pain and how environmental and life-style factors alter pain and its comorbid factors. Chronic pain is associated with anxiety, depression, cognitive dysfunction and changes in the brain. Stress and negative mood can exacerbate chronic pain, whereas positive mood, cognitive-behavioral therapies, exercise, social support, and mind-body and relaxation techniques can reduce the impact of chronic pain. NIH Center and offices focused on IM/CAM 4

5 Overview I. Introduction, What is Integrative Medicine? II. Review & discussion of clinical research Consortium WHITE PAPER III. Integrative Medicine at Hartford Hospital and the Future of Integrative Medicine Education The ACIMH is an institutional member organization of 72 North American academic medical centers and health systems. Its mission is to advance evidence-based integrative medicine and health in research, curricula and sustainable models of clinical care. Outline the role of evidence-based nonpharmacologic strategies for the management of pain and how they can be integrated with conventional approaches The problem Magnitude of the problem Impact of pain Economic impact Health disparities and pain Complexity of pain categorization Comorbidities associated with pain Healthcare workforce considerations Risk and lack of effectiveness of pain care strategies Opioids and other drugs Imaging, procedures and surgery 5

6 Solutions to the problem- Evidence-based Nonpharmacologic Pain Care (NPPC) Acupuncture Massage therapy Mind body directed therapies Spinal manipulation and manipulative therapies Biofeedback Movement therapies Frequency, dosage, timing Nutrition Economic benefits Magnitude of the problem Societal impact $ billion annually >100 million American adults have chronic pain LBP, neck pain, OA, H/A most common in US Pain prevalence will rise as chronic illnesses increase Pain impacts the individual, families, employers, healthcare system, and community Economic impact US spent 17.8% of it s GDP on healthcare 2015 (20% by 2025) Burden of opioid OD, abuse and dependency is $78.5 billion/yr Health disparities and pain Increased vulnerability to pain associated with: English as a second language Race/ethnicity (African-Americans, Hispanics undertreated) Lower income and education Gender (Women-misdx, delays, neglect, dismissal) Age (Children and elderly undertreated) Geographic locations Military veterans Cognitive impairments Surgical and cancer patients Magnitude of the problem Complexity of pain categorization Variability can obscure the magnitude of the problem Acute vs chronic (artificial metric) Central vs peripheral sensitization Neuroplasticity and the reorganization of somatosensory cortex Pain is subcategorized by anatomical site Comorbidities Physical, psychological, social, spiritual domains Mental health- 16% of Americans who have mental health disorders receive > 50% of all opioid prescriptions Pain and social rejection/isolation are experienced in the same parts of the brain Healthcare workforce considerations 49% of all dispensed opioid Rxs by PCPs Medical education is inadequate (mean 11 hrs in 3-4 yr) A national culture shift will be required to improve pain-related education and hence pain management 6

7 Magnitude of the problem Risk and lack of effectiveness of pain care strategies Despite medical advances, the prevalence and impact of pain is getting worse, not better Multifactorial Notion that pain can be fixed by a practitioner or procedure Education emphasizes the search for the appropriate dose rather than alternatives Patients are regarded as passive, rather than active participants in their own care- preventative, self-care Obsession with quantification of pain (the 5 th vital sign) Opioids and other drugs US prescribes 50 times more opioids than the rest of the world combined See chart Imaging, procedures and surgery MRI findings do not correlate well with pain intensity, functional impairment or better outcomes Surgery rates are highest in regions where imaging rates are highest Surgery performed to alleviate pain often does not achieve the goal More research is needed to understand the progression of acute to chronic pain The siloed approach in this country has not addressed the scope of pain this is where integrative medicine is different and more effective NIH National Pain Strategy, NAM, CDC opioid guidelines, mandate from Joint Commission, FDA, American College of Physicians (ACP) Clinical Practice Guideline (January 1, supports the use of nonpharmacologic therapies for pain) all recommend evidence-informed, comprehensive pain care New research about the impact on pain states by the microbiome, mitochondria, fascia, glia and neuroplasticity will likely impact the way we approach pain in the future 7

8 Solutions to the problem- Evidence-based Nonpharmacologic Pain Care (NPPC) Evidenced-based nonpharmacologic therapies are safe and effective components in comprehensive pain care NPPC can be opioid sparing NPPC can serve as stand alone therapies or with medicine or surgeries/procedures Additional benefits of NPPC Pain reduction reduce anxiety and depression Reduce nausea/vomiting Help sleep Increase well-being and commitment to selfcare Solutions to the problem- Evidence-based Nonpharmacologic Pain Care (NPPC) Acupuncture Massage therapy Mind body directed therapies Spinal manipulation and manipulative therapies Biofeedback Movement therapies Frequency, dosage, timing Nutrition Economic benefits PAST 8

9 Future Acupuncture Acupuncture has been practiced in China and other Asian countries for more than 4,000 years.[12-14] In China, acupuncture is part of a TCM system of traditional medical knowledge and is practiced along with other treatment modalities such as herbal medicine, tui na (massage and acupressure), mind/body exercise(e.g., qigong and tai chi), and dietary therapy.[15,16] In the United States, several different acupuncture styles are practiced in addition to TCM. These include Japanese acupuncture (e.g., meridian therapy), English acupuncture (e.g., five-element or traditional acupuncture), French acupuncture (e.g., French energetic acupuncture), Korean acupuncture (e.g., constitutional acupuncture), and American medical acupuncture. Acupuncture Acupuncture, a complementary therapy used in symptom management,[1-4] is used clinically to manage cancer-related symptoms, treat side effects induced by chemotherapy or radiation therapy, boost blood cell count, and enhance lymphocyte and natural killer (NK) cell activity. In cancer treatment, its primary use is symptom management; commonly treated symptoms are cancer pain,[4,5] chemotherapy-induced nausea and vomiting (N/V),[6,7] and other symptoms that affect a patient s quality of life, including weight loss, anxiety, depression, insomnia, poor appetite, fatigue, xerostomia, hot flashes, chemotherapy-induced peripheral neuropathy, gastrointestinal symptoms (constipation and diarrhea) and postoperative ileus.[8-10] Acupuncture is acceptable and safe for children.[11] 9

10 The Energetic Basis of Acupuncture & TCM Theory Basis is modulation of qi, the life force energy 12 major meridians Energy flows (or may be blocked) through the meridians Meridians exhibit lower resistance and can be mapped with dye Acupuncture applies an energetic stimulus enhanced by dual metal content and temperature gradient across needle Community Acupuncture Private Session Acupuncture Acupuncture & $$ Insurance High Variation 1- Check with Insurance 2- Do you need Referral 3- What Diagnosis are covered Pain, OA, Nausea etc. Opioids-Discuss Community Acp $ on 1 Acp $80 -$150 10

11 Nonpharmacologic Therapies for Acute Inpatient Pain with Opioid Sparing Acupuncture therapy for POST-OPERATIVE PAIN 1- Systematic reviews with meta-analyses Acupuncture post-surgical pain compared to sham acupuncture, controls and usual care Reduction in opioid need 21% at 8hr, 23% at 24h, 29% at 72h Reduction in opioid-related side effects nausea, dizziness, sedation, pruritus, urinary retention 2- Systematic reviews with meta-analyses Acupuncture after TKR pain and delayed opioid use Peri-op auricular acupuncture post-op pain and need for analgesic use compared to sham and usual controls; pain 48h = analgesics with less side effects 3- Intraoperative electrical stimulation of acupuncture points intraoperative opioid requirements, post-op pain, and LOS in the PACU What is Sham Acupuncture? 11

12 What is ear acupuncture (auricular therapy)? Ear acupuncture, also known as auricular therapy, is based on the principles of Traditional Chinese Medicine. Auricular therapy is widely used for many conditions, including addiction treatment, mood disorders, obesity, pain, and other conditions. This medical system emphasizes a holistic approach to medicine, an approach that treats the whole person. The acupuncture points found on the ear help to regulate the body's internal organs, structures, and functions. Basic Ear Anatomy Auricular therapy has a long history of use in China. It was mentioned in the most famous of ancient Chinese Medical textbooks, The Huangdi neijing or Yellow Emperor's Classic of Internal Medicine Written during the Warring States period ( BC). In modern times, auricular therapy has been shown to stimulate the release of endorphins. How is ear acupuncture used in a treatment? Ear acupuncture is generally incorporated into a regular acupuncture treatment. In addition to using acupuncture points on the rest of the body, your acupuncturist may select a few ear acupuncture points that they feel will be helpful for your particular condition. What are ear seeds and ear tacks? Ear acupuncture points may be stimulated for a longer period of time by using ear seeds or ear tacks. Ear seeds are small seeds from the Vaccaria plant. These seeds are held in place on the ear with a small piece of adhesive tape. Ear seeds may be left in the ear for a few days or up to two weeks. Ear tacks are very small needles with an adhesive backing. Ear tacks are inserted into the ear and left in the ear for a few days or up to one week. Shen men 12

13 Nonpharmacologic Therapies for Acute Inpatient Pain with Opioid Sparing Acupuncture therapy for NON-SURGICAL PAIN 1- Systematic reviews with meta-analyses Acupuncture effective for acute and subacute LBP ACP recommends acupuncture as first line treatment Acupuncture also effective for acute migraine 2- RCT with 300 patients with acute pain presenting to ED Acupuncture was superior to parenteral morphine for pain relief and onset of action; fewer side effects 3- Retrospective study of ED acute pain patients acupuncture decreased pain = analgesics, but also ANXIETY Systematic review with meta-analysis of acupuncture in ED: Acupuncture provided statistically significant, clinically meaningful, and improved levels of patient satisfaction with respect to pain relief in the emergency setting. Lower cost and low adverse effects profile Nonpharmacologic Therapies for Chronic Pain Acupuncture therapy 1- Meta-analysis of 29 RCTs with 17,922 patients Acupuncture for neck, LBP, knee OA, headache and migraine Acupuncture was significantly better than sham acupuncture and usual care for all conditions 2- Meta-analysis on long-term impact Effects of a course of acupuncture persisted at 12 months in trials with wait list or usual care controls 3- Systematic review with meta-analysis Acupuncture was better than controls for treatment of peripheral neuropathy due to diabetes, HIV, carpal tunnel syndrome and Bell s palsy 4- Large multicenter trial (14,161 patients) with chronic neck pain Acupuncture (15 sessions over 3 months) + routine care improvements in neck pain and disability compared to routine care alone The Anti-Inflammatory Actions of Auricular Point Acupressure for Chronic Low Back Pain Evidence-Based Comp & Alt Med. Vol. 2015, Article ID , 1-9 Methods- 61 pts with CLBP received APA or sham APA. Blood samples, pain intensity, & physical function collected at baseline and 4 weeks after treatment. Results/Conclusions: Subjects in real APA group had 56% reduction in pain and 26% improvement in function. Serum blood samples showed IL-1, IL-2, IL-6, CGRP, and IL-4. Sham APA group had 9% reduction in pain and 2% improvement in function, and minimal changes of inflammatory cytokines. Findings suggest APA treatment affects pain intensity through modulation of the immune system. 13

14 Acupuncture for pelvic/back pain Guided Imagery A therapeutic modality whereby directed thoughts and suggestions are used to guide the imagination toward a relaxed, focused state. A facilitator, audio material, or scripts can be used to guide the body to respond to the imagined state as though it were real. Healthjourneys.com Other IM Therapies Diet & Supplements Yoga Tai Chi Hypnosis Massage Bio-field Therapy 14

15 Use of Manual Therapy in the Treatment of Pain Use of Mind-body Therapies in the Treatment of Pain Nonpharmacologic Therapies for Acute Inpatient Pain with Opioid Sparing Massage therapy for POST-OPERATIVE and ACUTE PAIN 1- Systematic review with meta-analysis A single dose of massage post-surgical pain 2- Systematic review with meta-analysis Massage therapy was effective for treating pain and anxiety compared to active comparators in surgical pain populations 3- Massage is effective for pain reduction in post-cesarean section patients, thoracic surgery and cardiac patients Mind body directed therapies 1- Systematic review with meta-analysis Music therapy reduced pain in burn patients 2-Meta-analysis of 97 studies evaluating music for pain Significant pain intensity, emotional distress, and analgesic use (opioid and non-opioid) Guided imagery, hypnosis, virtual reality assisted distraction Reduce pain and medication use 15

16 Nonpharmacologic Therapies for Chronic Pain Massage therapy for CHRONIC PAIN 1- Systematic review by ACP Clinical Practice Guideline: Recommends massage for acute, subacute, and chronic LBP 2- Systematic review with meta-analysis Massage therapy was effective for treating pain compared to sham, no treatment and active comparators across all pain populations 3- Massage is effective for OA of the knee- optimal dose, 8 weekly one-hour sessions Spinal manipulation therapy (SMT)/manipulative therapy 1- Systematic review with meta-analysis SMT improves LBP for 6 weeks and is cost effective 2-Systematic reviews and meta-analysis Manual therapy is beneficial for OA in the knee and hip, plantar fasciitis, shoulder disorders, ankle sprains 3-ACP recommends spinal manipulation for acute, subacute, and chronic LBP Nonpharmacologic Therapies for Chronic Pain Mind body therapy for CHRONIC PAIN 1- MBSR (Mindfulness based stress reduction) Moment to moment awareness of breathing and attention without judgement to transform perceptions Systematic review with meta-analysis MBSR for LBP short-term improvements 2- Relaxation therapies (slow breathing, muscle relaxation) Favor parasympathetic NS cortisol Large meta-analysis Music chronic pain, emotional distress and opioid/non opioid intake 3- Biofeedback Self-care tool for physiologic modulation Meta-analysis for chronic LBP Found pain, depression, disability, muscle tension and better coping ACP Guideline recommends EMG biofeedback for chronic LBP Blue Shield of California- Guided Imagery Study 905 patients enrolled in study; women who were about to undergo hysterectomy (n=126) Insurance companies purchased $17.95 CD by Belleruth Naparstek Patients were instructed to listen to CD for 2 weeks prior to surgery if possible Post-operatively, patients using CD had less pain and shorter hospital stay than control patients; overall higher satisfaction Overall, Blue Shield saved about $2, per patient Schwab et al, Advances, (1):

17 Use of Yoga in the Treatment of Pain Nonpharmacologic Therapies for Chronic Pain Movement therapies for CHRONIC PAIN 1- Yoga Combines attention and meditation (Dhyana), breathing (Pranayama) and physical postures (Asanas) Cochrane review of yoga for nonspecific back pain Moderate supporting evidence for improvement in back function Systematic review/summary of reviews Yoga is beneficial for back pain, OA, RA, kyphosis, and fibromyalgia Other health benefits- EPIGENETIC ACP Guideline recommends yoga for chronic LBP 2- Tai chi Slow movements with attention to breath/meditation Systematic reviews and meta-analyses Tai chi is beneficial for OA and chronic pain syndromes ACP Guideline recommends Tai chi for chronic LBP Safety of Nonpharmacologic Interventions for Pain ACUPUNCTURE Low risk of adverse events Systematic reviews and surveys acupuncture is safe when performed by appropriately trained practitioners Infrequent minor side effects Feeling relaxed, tired and elated Itching at the insertion point Rare serious complications directly related to insufficient training Infection, pneumothorax MASSAGE Safe Minor complaints muscle soreness MANUAL THERAPY (Spinal manipulation) Adverse events include muscle soreness or transient increases in pain Rare serious adverse events stroke, cervical artery dissection, & neck injury BIOFEEDBACK Safe Rare side effects of headache, fatigue or sleep problems YOGA Mild-moderate side effects Self-limiting joint and back pain TAI CHI No adverse effects, mild aches and pains 17

18 Frequency, Dosing, and Timing of Nonpharmacologic Interventions for Chronic Pain Acupuncture Course will depend on patient, the term and severity of the condition Large meta-analysis of RCTs for chronic pain of head, neck, shoulder, knee 8-15 treatments over weeks for persistent benefit (12 months) Large meta-analysis that identified characteristics of the treatment (16-45 min; 6-20 needles) increased number of needle sites and more sessions were associated with better outcomes Ideally, at least 8 sessions, preferably 8-15 Community acupuncture is being studied Frequency, Dosing, and Timing of Nonpharmacologic Interventions for Chronic Pain Massage minute sessions weekly Number of sessions recommended has not been established Chiropractic/osteopathic spinal manipulation Variable schedules Weekly sessions for 4-6 weeks was slightly superior to back school or PT for chronic LBP MBSR Structured, standard 8 week program Yoga/Tai chi Given in group sessions Variable schedules Use of Diet and Supplements for Pain Management 18

19 Anti-inflammatory Diet and Supplements for Pain Management Nutritional status can either promote or decrease inflammation in the body Anti-inflammatory diet Prototype = Mediterranean diet Vegetables, fruits, legumes, nuts/seeds, healthy oils and whole grains Plant-based diet preferred or low animal protein Dietary anti-oxidants (essential for optimal mitochondrial health- mitochondrial dysfunction is root cause of many pain-related conditions) Anti-inflammatory Diet and Supplements for Pain Management Turmeric (curcumin) Used for peri-op pain with opioid sparing, joint and musculoskeletal pain, IBD Equal to NSAIDs for pain improvement Doses range mg daily Ginger Joint pain and primary dysmenorrhea 500 mg ginger rhizome q6hr Micronutrients Vitamin D deficiency common with chronic pain Magnesium deficiency associated with muscle spasm and neuropathic pain 19

20 Antiinflammatory Diet Mechanisms and Measurement of Inflammation Modulation of eicosanoid activity Turmeric suppresses COX-2 expression and nutmeg can inhibit TNF- release in animal studies Pro- and antioxidant effects Increased antioxidant food intake is correlated with lower CRP levels and with lower incidence of joint inflammation Insulin and glucose levels High dietary glycemic load associated with increased CRP levels (elevated levels precede T2 diabetes) Genetic and intracellular expression Mediterranean diet and omega-3 fats modulate gene expression related to inflammation Gastrointestinal dysbiosis Disruption to the gut microbiome can trigger a host of inflammatory diseases Overview I. Introduction, What is Integrative Medicine? II. Review & discussion of clinical research Consortium WHITE PAPER III. Integrative Medicine at Hartford Hospital and the Future of Integrative Medicine Education Our Goals for Integrative Medicine Clinical Care: Support IM clinical services for cancer patients, their caregivers, Hartford Hospital inpatients, patients with chronic disease, disadvantaged populations and members of the general public. Education: Enhancement of general health education programs on a wide variety of wellness, stress reduction, and chronic disease topics including a comprehensive nutrition education program and demonstration kitchen. Research: Conduct comprehensive clinical outcomes, effectiveness and mechanistic research on IM therapies. 20

21 Collaborative HHC Programs FY Hartford Hospital, Helen & Harry Gray Cancer Center Collaborative HHC Programs FY 2017 Cancer Institute Bone & Joint Institute Neuroscience Institute Hartford Pain Management CCMC Pulmonary Rehab Cardiac Rehab Women s Health IOL Consultations A Sustainable Model IM Physician consults Third party billing, FTE, contractor Acupuncture Third party billing, community, grant Massage Third party billing, intra- and extramural grants Yoga Two extramural foundation grants Reiki Volunteer Demonstration kitchen support BJI support and FTE MBSR Cash Inpatient/outpatient services Start up costs Cancer Institute and BJI support 21

22 Integrative Medicine, Avon The new Integrative Medicine treatment suite is located within the Hartford HealthCare Cancer Institute, Hartford Region in Avon. Phase one of the renovation has recently been completed; we have finished interior design and outfitting the administration space and treatment rooms. Waiting Room Waiting Room Main Hallway 22

23 As Hartford HealthCare and the Cancer Institute transition to one standardized electronic medical record EPIC, Integrative Medicine will be prepared with access to computers throughout the new suite in Avon. Electronic notes will be accessible in exam rooms, dispensary, Physician Consult Room and the Physician Charting Alcove. Physician Consult Room Physician Charting Alcove 23

24 Hartford HealthCare Bone & Joint Institute Hartford HealthCare Bone & Joint Institute Center for Musculoskeletal Health 24

25 Integrative Bone & Joint Institute Integrative Bone & Joint Institute Demonstration Kitchen 25

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27 Integrative Approach to Pain Management- Take Home Most IM strategies reviewed here are underutilized because of a lack of evidence dissemination, education and reimbursement There are many IM modalities that are safe, have evidence to support their use and are cost effective Further education of practitioners and patients is necessary; focus on comprehensive, interprofessional (multi-disciplinary) Further research is needed to explore both therapeutic and economic impact Federal and state policy must increase access to and reimbursement for these evidence-based IM treatments Thank you! To reach us, please call: