A day without sunshine is like, you know, night

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“A day without sunshine is like, you know, night.” — Steve Martin

I grew up laughing at Steve Martin, arrow-through-the-head gag, King Tut and all. I do not suppose Mr. Martin had any deeper goals with this statement beyond the sheer comedy of beginning a sentence that seems to be steering the reader to some profound truth and then smacking them with simple, obvious, logic. I came across this morsel of brilliant nonsense as I was looking for a bit of wisdom to start this editorial on the struggle to bring integrative medicine (acupuncture, massage therapy, yoga, etc.) into mainstream federal medicine. It struck me as a very fitting quote for this editorial. Let me see if I can explain.

Since 1990, overdose deaths from illicit, prescription and over-the-counter drugs have more than tripled in the United States.1 A particularly concerning fact about these deaths is the increasing role prescription drugs are playing in this issue. The rise in deaths has been paralleled by a 300% increase in the sale of pain medications. Prescription drug overdoses were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin deaths combined.2

Startlingly, we have discovered the primary source of the drug problem in the United States; it is us. I am not suggesting that physicians prescribe pain medications for illegitimate reasons. On the contrary, I suspect these drugs are prescribed with the best therapeutic intentions, but the side effect profile of these medications, particularly opioids which promote a feeling of euphoria coupled with significant respiratory depression in some patients, can lead to tragedy through medication diversion, abuse and misuse. I also am sensitive to the fact, as a pain physician, that many chronic pain and cancer patients depend upon these powerful medications, under close supervision of their doctors, to achieve a reasonable quality of life.

Furthermore, this discussion is not only about opioids. Other routine pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), also carry important often misunderstood risks. The American Gastroenterological Association notes that more than 100,000 people are hospitalized and more than 16,000 die due to bleeding stomach ulcers associated with NSAIDs. Again, despite these well-known risks, these medications play a vital role in pain management. I certainly use all of these medications in my own practice and would be hard-pressed to manage my pain patients if these tools were suddenly removed from my medical toolbox.

Nevertheless, we do seem to have a problem with prescription medications in this country. We are a society weaned on the idea that there is a pill for every problem in life. I cannot watch television anymore without being subjected to images of some ruggedly handsome American male (50-something) driving through the desert in his classic car, confident in his abilities to sexually please whomever has left the light on for him as he arrives home. I also am concerned about “low-T” being the source of my fatigue at the end of the day, rather than the fact that I am not 18 anymore, as I observe happy males on television living their perfect lives, seemingly from a simple drug smear on their armpits. I know there are similar examples for women, but these are the commercials that make me feel most inadequate.

Drugs are big business in this country, and we are bombarded by reminders that our ills can be erased if we would only “talk to our doctors about the new purple pill.” This constant messaging barrage by the pharmaceutical industry is not without consequences. Our patients often have an expectation that when they visit the doctor they can walk out of the office with a prescription to make them all better. Perhaps, as a profession, we have been too quick to oblige our clients’ desires for pills. Granted, it is much easier to prescribe a pill and move on to the next patient. Usually, both patient and provider leave this interaction happy and unscathed. Increasingly though, this approach is becoming both more costly and in some cases, deadly.

In federal medicine there has been an aggressive push to identify and incorporate nonpharmacologic treatments into our health system. I recently completed my medical acupuncture training and, with other like-minded colleagues, we are introducing acupuncture into our acute pain medicine service at Walter Reed National Military Medical Center. This effort has most often been met with enthusiasm from our patients. In my own family, I have added acupuncture to the post-surgical pain management of my middle daughter, resulting in a significant reduction in her opioid and NSAID use. And, acupuncture and yoga are significant research priorities for the DoD.

While I obviously am excited about and applaud thes direction federal medicine is taking, many more in our system remain skeptical and far less enthusiastic about these changes.  Naysayers point out the inconsistencies in patient responses to acupuncture or the paucity of acceptable peer-reviewed science. These same arguments are used for most integrative medicine modalities.

I agree that far more research into these modalities is required. I do know that for many patients with many common conditions, these therapies are effective, extremely safe and can be very economical if supported within a health system. So I will conclude this editorial by asking the reader a question: If we could reduce any significant fraction of the prescription medications we are writing  today by incorporating integrative techniques, why would we not take that path? To channel some Steve Martin, “A patient who leaves my office treated and satisfied without a prescription is like, you know, success.”

1 CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6

2http://www.cdc.gov/homeandrecreationalsafety/rxbrief/ accessed 1 November 2013.

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