Guidelines For Treating Pain After the Epidemic
Pain. Its a big deal. Its been with us (meaning human and other creatures ) since far back in evolutionary times, so we can assume it has served a purpose. No doubt there has been awareness of pain for as long as we have possessed awareness. Nevertheless, the way we think about and treat pain has varied tremendously over the years and across the landscape of culture. As a case in point, let us look at the recent evidence based clinical practice guidelines for the treatment of acute, subacute and chronic low back pain, developed by the American College of Physicians, and published in the Annals of Internal Medicine in April 2017. These new guidelines recommend a shift in the way we treat pain, from drug based treatments to other kinds of therapies.
There has been growing awareness on the part of the medical community, and its regulating and reimbursing bodies, of an epidemic involving overprescription and overuse of opioid pain medication (amongst other varieties of pharmaceuticals), and that this epidemic has caused great harm, suffering and destruction. This is a crisis that grew in response to an earlier discovered “pain epidemic” of under-treated pain. We have now seen, however, that overall, the response was more effective at promoting drug sales than it was at relieving suffering.
1996 was the year that the “war on pain” was declared* and pain was declared the “fifth vital sign” at the urging of the American Pain Society. Historically, an increased focus on a given health care condition often parallels the emergence of a new and profitable medication. The year 1996 also turns out to be the year that the first “safe” extended release opiates were approved and Oxycontin hit the market. In 1997, after the FDA issued revised draft guidelines for broadcast DTCPA (direct to consumer pharmaceutical advertising), the budgets for consumer drug advertising skyrocketed. These increases were echoed in enormous rises in the amount of prescriptions written for extended release opioid pain medications, numbers of individuals taking such meds (whether by prescription or diversion), and the resulting overdoses and addiction. It has taken nearly 20 years for the facts to catch up, but it turns out these meds aren’t as good at managing pain, particularly chronic pain, as had once been thought. It is time for us to reframe the questions around pain management.
Evidence Based Medicine
Now, there is nothing like having to foot the bill for medical services to make a third party payer (commercial or governmental) get behind the idea of evidence based medicine. I realize readers who are neither researchers nor health care providers may assume that medical treatments being performed or prescribed for a condition have somehow been shown to be helpful for it. Nevertheless, you would be surprised to know how much of modern medical practice has not, for all its biomedical origin, been subjected to statistical proof of effectiveness for the purpose for which it is used.
The proliferation of medical research in the last 25 years made it impossible for most practicing physicians across the globe to stay on top of it all, and the term “Evidence Based Medicine” was coined in 1990 to describe the process of sifting through it critically to transform research into useful guidelines for clinical practice. As a family physician, I first started to hear about evidence based medicine in the context of the pretreatment review by a health insurance company of new, expensive and risky cancer treatments such as bone marrow transplants, treatments that might be the last or only hope for a patient’s survival. The treatment would be approved if research had already provided evidence of benefit for that specific condition, otherwise it could be rejected as “experimental”, and hence not covered.
Recommendation: Try Nondrug Therapies First for Nonradicular Low Back Pain
This brings us back to the ACP recommendations for treatment of low back pain: the acute, the subacute and the chronic. They are based on analysis of hundreds of RCTs (randomized controlled clinical trials) published since 2007 studying non-invasive pharmacological therapies (non-steroidal anti-inflammatory meds such as ibuprofen, muscle relaxers, corticosteroids and opioids) and non-pharmacological therapies (heat, massage, acupuncture and spinal manipulation, exercise, mindfulness-based stress reduction, tai chi, yoga, and cognitive behavioral therapy, to name a few). It should be noted that the analysis did not include interventional treatments, such as surgery or epidural or other injections, and did not include topical medications such as creams and patches. It also excluded consideration of radicular pain, in which pain, numbness or weakness in the legs might signal nerve compression. The researchers looked at reduction of pain and disability, improvements in quality of life, return to work and other functional metrics, adverse effects, and patient satisfaction in order make recommendations about which treatments worked best. Here is what they found.
For both short term (acute pain of 1-4 weeks and subacute up to 4 months duration) and chronic low back pain (over 4 months) non-drug treatments came out on top and were strongly recommended as the first line of treatment whenever possible. The treatments for acute low back pain that had the best evidence to back them up were acupuncture, massage, spinal manipulation and heat. For chronic low back pain, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control and other exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy and spinal manipulation were all given strong recommendations to be chosen as initial therapy; pharmacologic treatment with NSAIDS, and a few other non-narcotic medications were second line recommendations, with opioids a distant third, to be considered only if non-pharmacological methods did not work. In other words: acupuncture, yoga, massage, and heat were recommended over Motrin. Opioids placed last.
Implications for Healthcare Policy
It is my strongly held opinion that since current guidelines show that massage, acupuncture and heat are better for the treatment of low back pain than pain medication, then these treatments should be easier (or at least as easy) to obtain than drugs. Acupuncture and other modalities shown to outshine opioid and non-opioid medications in the treatment of low back pain are services that should be available on all commercial and public health plans to those who will derive benefit. Massage and simple things like heating pads should be covered benefits. As a physician, I believe with all my heart that health care is a right and not a privilege or a luxury item. When I speak of the right to healthcare, what I mean is that the best of medical care must be available to all, and that this right is not limited to professional services and pharmaceuticals, but includes health related practices and products to which not all currently have reasonable access. I believe we can create a health care system that makes it easier to get hooked on yoga or tai chi than on pain meds.
Honoring Touch: Therapies that are Older than the Hills and Things that are Hard to Measure
Let us now circle back to look at the ACP evidence based recommendations from a different perspective. Allow me to point out that most of the recommended non-pharmacologic treatments, such as heat, massage and acupuncture, are older than the hills, inexpensive to administer, and derive from practices used by diverse cultures around the world. Seriously, now, how wonderful is that?
It is frankly poetic, that an ancient practice, such as the “application of superficial heat,” likely one of the most ancient of methods devised by early humans to alleviate suffering, should outperform laboratory made formulations du jour. I mean this with no disrespect. Modern medicine need not bristle in self defense, for it diminishes not our appreciation for the works of today’s minds when we pay tribute to the brilliance of our deep ancestors. They taught us to take a warm stone from the fire or hearth and wrap it in a skin or flannel, or prepare a hot poultice of herbs to soothe a sore spot. Its universal. It may sound like a stretch, but I really do see in this a confirmation of my faith in humankind’s longstanding wisdom and ability to heal itself.
These non-pharmaceutical interventions need not be defined solely in terms of what they are not, that is to say, their status as not being drugs. Acupuncture, massage, exercise, yoga, and manipulation share many useful qualities, apart from their not being pharmaceutical interventions. By and large these are interactional therapies. They involve direct, usually one on one, contact with another human being who is focusing their attention, knowledge and touch on helping you relieve your suffering.
This is profound. By their very definition these modalities include human interaction and understanding, and at their best involve kindness and empathy as well. In some of these practices, such as tai chi or yoga, the practitioner works with a student, teaching ways of breathing, or of coping by mindfully being in the world, or harmonizing their body. In others, it is the use of the body and vital energy of the practitioner him or herself that is the medium through which the treatment must flow. In massage, manipulation and acupuncture, as a practitioner, you are the tool and the bearer of the energy that moves that tool. You are also the intuition that knows how hard to touch to gather information about the patient’s body, how hard to press to release restriction from the tissues, and the experience that witnesses the release of emotions from their fascial lodgings.
So Hats Off to Touch Based Therapies!
Let us take a moment to praise therapies that by their very definition include all the messy things that researchers over the years have striven so hard to remove so that we could study capsules unencumbered by the traces of human touch. Touch. Even in complementary and alternative medicine research we tend to slink past that part, as if it were a little nasty. Unclean. The kind of concept upon which all of us seem to have mutually agreed to “not go there.”
And yes, of course, all around the world, scientists in laboratories right now are seeking to uncode the mysteries of just how it is that empathy and meditation and healing touch modify neurotransmission, or RNA transcription, or some other molecular feats of unimaginable wonder. But let us not forget that these amazing human practices on the verge of being uncoded (and God forbid, patented), were first conceived by and transmitted through the wizened bodies of African and Tibetan and Meso-American healers, who were researchers in their own right! Touch based therapies have kept us going throughout the ages of our lives, and I believe it is in part because they have the capacity to absorb and distribute such large volumes of compassion and hopeful expectation, that their powers are large. And if some portion of the therapeutic effect obtained through these modalities comes from faith in the healer, let that not be cause to deny credit for the success of the healing!
Yours in health and healing,
Marsha Haller, MD
* Have you ever noticed that whenever a war is declared on a concept, as in the war on drugs or the wars on terror, the outcome is doomed to failure? It may have to do with our trouble appreciating that some problems cannot be extricated by surgery or confrontation and that those declaring the war may have more of a stake in maintaining the problem than we realize.