to get the best of both worlds Integrative approaches to pain ...

Downloaded from bmj.com on 12 November 2008 Integrative approaches to pain management: how to get the best of both worlds Brian M Berman BMJ 2003;326;1320-1321 doi:10.1136/bmj.326.7402.1320-a Updated information and services can be found at: http://bmj.com/cgi/content/full/326/7402/1320-a These include: References This article cites 18 articles, 7 of which can be accessed free at: http://bmj.com/cgi/content/full/326/7402/1320-a#BIBL You can respond to this article at: http://bmj.com/cgi/eletter-submit/326/7402/1320-a Receive free email alerts when new articles cite this article - sign up in the box at the top left of the article Rapid responses Email alerting service Topic collections Articles on similar topics can be found in the following collections General practice / family medicine (6899 articles) Immunology (including allergy) (7487 articles) Headache (including migraine) (460 articles) Pain (neurology) (3072 articles) Sleep disorders (neurology) (209 articles) Stroke (2578 articles) Hospice (701 articles) Psychotherapy (222 articles) Complementary medicine (591 articles) Sleep disorders (185 articles) Sleep disorders (respiratory medicine) (208 articles) Connective tissue disease (496 articles) Degenerative joint disease (852 articles) Musculoskeletal syndromes (1750 articles) Osteoarthritis (211 articles) Rheumatoid arthritis (293 articles) Communication (225 articles) Health education (4569 articles) Health promotion (5584 articles) Sociology (2914 articles) Notes To order reprints follow the "Request Permissions" link in the navigation box To subscribe to BMJ go to: http://resources.bmj.com/bmj/subscribers Downloaded from bmj.com on 12 November 2008 PAIN Managing pain A good doctor-patient relationship can help improve pain management. But it requires help from other healthcare professionals, argues nurse consultant Eileen Mann cientists are beginning to understand how and why we feel acute pain, and the complex interplay of neurones and messenger molecules that lead to its perception. However, researchers are only just starting to explain the contribution of emotional affect, cognitive function, and how the human response to feelings such as anger, frustration, depression, anxiety, fatigue, and hopelessness can have an impact. Given the myriad influences on pain perception, it becomes clear that applying a traditional biomedical model may fail some sufferers as it does not routinely take into account the multidimensional nature of pain. If strong analgesia or surgery is offered to patients S whose pain may have become chronic and is intensified by the complex interplay of psychosocial factors, this may induce iatrogenic damage caused by the medicine or the medical intervention itself. The general pattern of current medical training and Western attitudes to disease may make it difficult for a doctor to fully believe a report of pain in the absence of identifiable organic pathology. Keys to improvement On a practical level, the keys to improving pain control are the same as for any clinical activity: good communication, comprehensive assessment of the patient, and giving a proper and thorough explanation of treatment options. Effective communication between doctor and patient and recognition of the contri- Integrative approaches to pain management: how to get the best of both worlds Despite the advances in conventional pain treatment, many patients look beyond the mainstream. Brian Berman considers the alternatives Modern medicine has few good answers to the problem of chronic pain and, as a result, people with chronic pain often turn to complementary medicine. In most cases, people use complementary and conventional medicine concurrently, hoping perhaps to find the “magic bullet” cure but also realising they need to find other ways to cope. A study published in JAMA has shown that people often turn to complementary therapies out of a desire to find approaches that are more congruent with a mind-body-spirit philosophy (not merely treating symptoms) and because they want to play a role in their own healing. None the less, doctors are often ambivalent about the role of complementary 1320 approaches, partly from a lack of knowledge but also from a feeling that good practice should be based on scientific evidence. As commendable as the scientific approach is, clinicians may be missing the boat by resting their case on the evidence argument and dismissing complementary medicine. Patients are becoming increasingly well informed and want to be treated as partners in their care but, finding or anticipating ambivalence among their primary care providers, tend not to divulge their concurrent use of complementary medicine. This has implications for the doctor-patient relationship, which should embody mutual trust and shared decision making, and is not in ALEXANDER BLAIR//MANFRED RUTZ/PHOTONICA the best interest of patient or doctor. Safety is the most obvious concern about lack of disclosure (for instance, the potential for negative drug and herb interactions such as between warfarin and ginkgo biloba). However, we should also look at the potential of complementary therapies to give people more ways to help themselves—to reduce or cope with not only pain but also other aspects of chronic conditions such as anxiety and stress, or to change to more healthy lifestyles. Mind-body therapies The most obvious self help approaches are mind-body therapies. Many approaches, usually cognitive behavioural methods, are already incorporated into multidisciplinary pain programmes, but others—such as hypnosis, Qi Gong, and meditation—are less well accepted. In 1996 the US National BMJ VOLUME 326 14 JUNE bmj.com Downloaded from bmj.com on 12 November 2008 bution made by other members of the health team, such as nurses, physiotherapists and carers, can provide a more complete picture of the patient’s experience and widen treatment options. Clinicians need to find out details of the pain—its nature, evolution, precipitating and relieving features—as these may provide clues to its cause and treatment. If analgesics are prescribed, by asking the patient what the effect is the clinician will be able to decide if the medication is appropriate, whether the dose is adequate, and how frequently the drug should be taken. Clinicians must also find out about the patient’s experience of unacceptable side effects as many patients may regard these as unavoidable and decline further analgesia. Some people may accept pain as unavoidable and not appreciate the benefits of effective pain control. Not all chronic pain will respond to currently available analgesia, and non-pharmacological treatments may represent the most effective approach. Nonpharmacological treatments are routinely incorporated into the care offered by multidisciplinary pain management teams. Acute pain After trauma or surgery, pain will be acute and may be severe, but the mechanisms of acute pain are better understood than those of chronic pain, and acute pain will usually respond well to pharmacological treatments. Patients should be told of the hazards associated with poorly managed acute pain, such as serious cardiovascular complications. Uncontrolled pain can also cause sleep disturbance, anorexia, muscle wasting, and depression. Unless the positive benefits of effective analgesia are reinforced, poor communication and misinformation may strengthen erroneous ideas, such as the concern that strong analgesics are addictive. ments and then modifying treatment is certainly time consuming. Good pain management and strategies for patients’ comfort are the very essence of nursing. However, many nurses, like patients, can feel powerless when doctors do not act upon their requests for additional or alternative analgesia. Even when effective analgesia is prescribed, many patients may feel they don’t want to trouble the busy nurses by telling them when they are in pain, a factor that regular assessment should overcome. It is nurses on acute wards who tend to spend most time with patients. Unlike doctors, they cannot easily withdraw when patients are distressed and in pain. needs. Even when the treatment fails to add substantially to pain relief, patients may still perceive benefit from a holistic, empathetic approach and the feeling that their pain is taken seriously. These valuable strategies also form the basis of care in multidisciplinary pain management clinics. If the principles of alternative therapists could be combined with a carefully assessed, evaluated, and flexible pharmacological regimen, much of the misery of pain could be reduced. It may be time to take a multidimensional approach to managing pain. The internet is an extemely valuable resource giving access to the latest research on pain management. Visit: www.painsociety.org; www.jr2.ox.ac.uk/bandolier/booth/ painpag; and www.cochrane.org.uk Eileen Mann nurse consultant pain management Poole Hospital NHS Trust and IHCS Bournemouth University, Poole BH21 2JB eileens_mail@yahoo.com Alternative therapies Frustration due to poor experience of pain management may lead patients to consult alternative practitioners. Alternative therapies can offer an individual approach tailored to their specific Nurses Carrying out detailed and frequent acute pain assess- Institutes of Health held a technology assessment conference on mind-body therapies for pain and insomnia, which found considerable evidence for their use, especially as adjunctive treatment. In many cases, a multidisciplinary approach that includes some form of stress management, coping skills training, cognitive restructuring, education, and possibly relaxation therapy is helpful for chronic conditions such as low back pain and rheumatoid arthritis and osteoarthritis. Relaxation and thermal biofeedback can be useful for recurrent migraines, while relaxation and electromyography muscle biofeedback, used alone or adjunctively, may help recurrent tension headaches. Finally, hypnosis, group therapy, relaxation, and imagery can significantly improve recovery time and alleviate pain when used in childbirth, before surgery, or during invasive medical procedures. Acupuncture In 1997 a National Institutes of Health consensus conference on acupuncture BMJ VOLUME 326 14 JUNE bmj.com concluded that promising results have emerged for acupuncture, used alone or as a part of a comprehensive management programme, for several pain conditions. Although the quantity and quality of research is as yet insufficient for definitive judgments about its usefulness, its credibility as a pain treatment has been enhanced by basic science experiments showing that acupuncture needling releases endorphins and other neurotransmitters in the brain. Some of the strongest clinical evidence is in the treatment of dental and temporomandibular dysfunction pain, and research findings are promising for idiopathic headaches, fibromyalgia, and osteoarthritis. In the case of chronic pain and back pain the evidence is inconclusive, and its effectiveness has not been supported for neck pain. In general, acupuncture seems to be safe in the hands of experienced, licensed practitioners, though disposable needles should be used. Chiropractic and massage Many people turn to chiropractic and massage for pain relief. Chiropractic usually involves manipulation of the spine, whereas massage applies pressure and traction to the soft tissues. Research on both is inconclusive, but a review by the US Agency for Health Care Policy and Research found that chiropractic is beneficial for acute back pain but that the evidence to support its use in chronic back pain is insufficient. Interestingly, patients often express greater satisfaction with chiropractic care than standard medical care even when the improvements in pain and disability are the same. A recent study attributes this greater satisfaction to communication of self care advice and explanation of treatment. Massage may help low back pain and noninflammatory rheumatic pain. 1321 Downloaded from bmj.com on 12 November 2008 PAIN Time for a fresh look at complementary medicine Edward Baldwin argues that patients will benefit if complementary and conventional practitioners do their homework and keep an open mind cientific rigour does not always go with complementary and alternative medicine. But the need for rigour is sometimes as evident in conventional medicine. Having been a user of complementary and alternative medicine for nearly 20 years, and finding myself more recently in positions where I have tried to draw attention to some of the remarkable things that seem to be happening in the field, I want to stress the need for clear thinking if we are to discover what works, to what extent, and for whom. My first experience of the unusual was 35 years ago. Having damaged my knees through too vigorous an outing in the British hills, I tried various forms of conventional medical treatment with no success. Three years later, hobbling with knee bandages, I was directed to a spiritual healer, who spent half an hour waving his hands over my knees. I shall never forget my astonishment at levering myself out of bed the next morning to find the pain had vanished, never properly to return. What is the orthodox explanation for this cure? The placebo effect. But no one has asked me what I in fact expected. Since the placebo effect may depend on the patient’s conscious or subconscious attitudes to treatment, this might be thought relevant. It would be encouraging if well conducted studies had been done to discover what patients do expect in varying situations, but my impression is that this has not been a research priority. How likely is it that a patient who has consulted a succession of the best white coats, and has had three years of failure and pain, will expect to be cured by a blind old man without qualifications? And if the placebo effect is so powerful—because my cure, though not total, was permanent—why did it not manifest itself for any of the previous orthodox interventions where I did expect results? I conclude that the placebo effect is a possible, but unlikely, explanation. The suspicion that “placebo effect” can be a BMJ VOLUME 326 14 JUNE bmj.com Herbal medicine Studies have found avocado and soybean unsaponifiables and devil’s claw to be effective in treating osteoarthritis pain, while the evidence for the herbal preparation Phytodolor and topical capsaicin is promising. The use of γ linolenic acid— found in borage seed oil, evening primrose oil, and blackcurrant seed oil—is supported by moderate evidence from trials in patients with rheumatoid arthritis. The evidence is strong for the use of chondroitin sulphate, glucosamine, and S-adenosylmethionine (SAMe), particularly for pain related to osteoarthritis. All these treatments seem to be safe. S cover for the discomfort the medical mind experiences when faced with the unusual is reinforced by the tendency of doctors to give explanations before they have ascertained the facts. Beata Bishop writes well of this in her account of recovery from metastatic malignant melanoma by means of an organic vegetarian diet. When she attempted to “interest some doctors in the life-saving potential of the Gerson therapy… With two exceptions all the doctors whom I approached chose to make categorical statements rather than ask questions.” Reasoning is not the only area in which many commentators on complementary and alternative medicine discard their usual rigour: this is also evident, less excusably, over basic facts. Last year a general practitioner writing in the Sunday Times on 12 June about Michael GearinTosh’s account of his unconventional journey through multiple myeloma wrote “not that coffee-ground enemas can cure cancer.” No, and neither can anaesthetics. But just as the latter is indispensable in cancer surgery, so the former is a necessary adjunct to the Gerson and some other therapies, without which the rapidity of the process of tumour breakdown can be overwhelming. Neither claims to cure. So, complementary medicine practitioners, please think about, question, and test what you do, and avoid comfortable assumptions. And, medical commentators, please do your homework as rigorously with complementary and alternative medicine as you would expect to do in your own disciplines. In this way patients are most likely to benefit. Edward Baldwin was chairman of the British Acupuncture Accreditation Board 1990-9, joint chairman of the parliamentary group for Alternative and Complementary Medicine 1992-2002, and served on the House of Lords Science and Technology Select Committee inquiry into complementary and alternative medicine in 2000. House of Lords, London SW1A 0PW Homoeopathy Research in homoeopathy, one of the more controversial complementary therapies, has shown some interesting results for both classical and complex homoeopathy in the treatment of rheumatic syndrome. The studies included in a recent review were small, but most were of high methodological quality, and all showed that homoeopathy was twice as effective as placebo. As homoeopathic prescribing is highly individualised to a person’s “constitutional picture” rather than to specific diseases, future research will need to meet this challenge as well as explore a plausible mechanism of action for homoeopathy. Good communication When considering integrative care, using the best of both complementary and conventional approaches, lack of knowledge can cloud the waters, and lack of communication—between physician and patient but also between conventional and complementary practitioners—can make navigation difficult. Steering a clear course will require finding a complementary therapist who is well trained and preferably a member of a professional organisation. Furthermore, doctor, patient, and complementary provider will need to communicate openly and monitor progress together. Brian Berman professor of family medicine University of Maryland School of Medicine, Baltimore, USA bberman@compmed.umm.edu GEPETTO/PHOTONICA Editor’s note: We did try to commission a piece on conventional pain therapies in order to balance these articles, but failed to get something we felt appropriate. If you want to read more about the advances in conventional pain treatments see Management of pain by Anita Holdcroft and Ian Power, BMJ 22 March 2003 1322