“You know what they call alternative medicine that’s been proved to work? – Medicine.” ~Tim Minchin
*Editor’s note: This month’s editorial was co-written by retired Lt. Gen. Eric Schoomaker.
A recent announcement of a very generous endowment by Susan and Henry Samueli for the University of California-Irvine to establish a medical school and health university integrating conventional and complementary principles and practices has elicited much interest.1 Coupled with the growing efforts of many of the leading U.S. health universities and medical schools to incorporate evidence-based complementary and “whole person” approaches to medical care, this trend has been met by many in federal medicine with enthusiasm. Many of us have undertaken active efforts to introduce comprehensive, patient-centered, team-based, multidisciplinary, evidence-based approaches to pain management into the departments of Defense and Veterans Affairs.
Federal medicine is mindful of the enormous contribution this integration of the best of both complementary and conventional health and medicine can make to the care we deliver. By relieving the suffering of those burdened by the most common complaint for which our patients seek care—pain—we are also combating the root cause of an unprecedented national opioid addiction epidemic. But all who heard this news do not share our enthusiasm.
The principal objections to this new endeavor appear to emanate from two sources. The first is that complementary health and medical practices are not based in science or evidence. While the fundamental mechanisms of many of these practices are not yet well-established or understood, there is growing evidence of their effectiveness from rigorously designed and conducted clinical trials for a variety of these modalities in the management of pain—especially chronic pain. Acupuncture, Tai Chi (and probably Qi Gong), medical massage, yoga, music therapy, chiropractic, and mindfulness meditation have all been identified as effective in the management of acute and chronic pain of the lower back, neck, post-operative discomfort, cancer pain and other forms of debilitating pain. Contributing to our growing confidence in their use is the more recent discovery that acute and chronic pain are fundamentally two different conditions. While acute pain is most often the result of tissue injury and nociceptive nerve stimulation that if poorly managed can become chronic pain, chronic pain—pain that lingers for two to three months or longer—is not a symptom of another problem but a brain disease of its own.
Highly individuated for each pain sufferer, chronic pain involves brain centers for emotions, memory and association among these and other sites that are often as distinct and different for each patient as fingerprints. The brain is the site of action for many, if not all, of the complementary treatments. Furthermore, we are learning more about the role of connective tissue such as fascia—the thin membranes that cover many structures in the body, such as muscles and bone. These may serve a much more important role in communicating physiological relevant information across the body. Fascial planes are among those elements that acupuncture needles and other forms of therapeutic needling interact. Our lack of fundamental understanding of these therapies may lie as much in our lack of a full appreciation of many bodily functions. It is interesting that medical science does not necessarily have a full understanding of the mechanisms of many accepted therapies, and yet similar concerns are not raised. Volatile anesthetics, for example, are used daily in the United States despite the lack of a complete understanding how these medications produce the anesthetic effect.
The other, more-common objection to the integration of complementary and conventional pain management practices are from those who resist changing our current fee-for-service healthcare delivery that does not focus upon optimal patient outcome, including restoration of function, does not remunerate for team-based or interdisciplinary care and who feel that our current drug- and procedure-focused approaches are sufficient. These critics ignore the clear linkage between poorly managed chronic pain and opioid addiction, the dearth of evidence for the utility of chronic opioids for most chronic pain and the growing consensus for alternative approaches to drugs and invasive procedures as a first line treatment of pain.
Our own experience with those on active duty, veterans and their families is that our patients are very receptive to these complementary therapies. Many of our more grievously wounded patients tell us that, had they known how debilitating and unending the use of chronic opiates and opioids was, they would have refused the treatment from the beginning. They are further encouraged by our focus on restoring optimal function by including functional disruption and pain interference with sleep and activity or perturbation of mood and stress in our measurement of pain effectiveness rather than a simple numeric scale that provides little clarity of the impact of pain.
We commend all who have demonstrated the courage to integrate good evidence-based complementary approaches to pain management into the conventional academic and clinical medical world. We and they are seeking a means to break out of our current chains of traditionalist reductionist thinking and profit motive in delivering care for pain. Albert Einstein said, “We can’t solve problems by using the same kind of thinking we used when we created them.” We wholeheartedly agree.
1https://www.usnews.com/news/healthcare-of-tomorrow/articles/2017-09-18/ucirvine-to-launch-new-college-and-integrative-health-initiative-with-200m-from-samuelis. Accessed Sept. 28, 2017.