Management of chronic pain using complementary and integrative medicine

Chronic pain is a complex, debilitating condition which makes life almost unbearable for many patients. There are no good treatments except for treating the underlying medical condition, if possible. Those suffering from chronic pain have twice the risk of MI, depression, and debilitation affects not only themselves, but also their caregivers and loved ones. It is little wonder that alternarive therapies are used, since there are no good traditional treatments.

Addictive medications such as opioids are only short term fixes, and eventually exacerbate the societal burdens, as well as the undividual ones. Cancer patients are among the most affected, as well as patients with chronic orthopedic/ arthritic and neurological degenerative disorders, as well as diabetic patients with peripheral neuropathies. A major research effort is needed for truly non-addictive treatments. In view of the huge societal interest in this area, NIH and other major research entities should focus on this area of greatest need, without delay!

The article by Chen et al (1) has given comprehensive information on the role of various complementary and integrative medical approaches to chronic pain management. The evidence based on scientific studies deals with most of the available complementary medicine groups. However, the role of Homeopathy has not been given enough information. Homeopathy seems to be effective in many chronic conditions especially rheumatic diseases (2). Though research in homeopathy is limited, evidence from other conditions such as fibromyalgia, osteoarthritis and rheumatoid arthritis showed to be inconclusive due to lack of high quality evidence (3-6). Positive results were obtained for fibromyalgia using homeopathy (7). Our individual experience showed getting relief from back ache with homeopathy without any side effects, though it took about two weeks to get relief from the pain and with no recurrence till one year. We think that there is a lot of scope in the practice of homeopathy in chronic pain relief. The limitation of homeopathy is that it functions on individualisation of treatment with no specific regimen which can be universalised due to individual differences in body reactions, behaviour and emotions.

References

1. Chen L, Michalsen A. Management of chronic pain using complementary and integrative medicine. BMJ 2017;357:j1284.
2. Jonas WB, Linde K, Ramirez G. Homeopathy and rheumatic disease. Rheumatic Disease Clinics of North America, 2000; 26: 117–123.
3. Perry R, Terry R, Ernst E. A systematic review of homoeopathy for the treatment of fibromyalgia. Clinical Rheumatology, 2010; 29:457–464.
4. Boehm K, Raak C, Cramer H, Lauche R, Ostermann T. Homeopathy in the treatment of fibromyalgia – A comprehensive literature-review and meta-analysis. Complementary Therapies in Medicine, 2014; 22: 731–742.
5. Long L, Ernst E. Homeopathic remedies for the treatment of osteoarthritis: a systematic review. British Homeopathic Journal, 2001; 90: 37–43.
6. Saha, Koley M, Medhurst R. A meta-analysis of the randomized controlled trials of individualized homeopathy in rheumatoid arthritis. World Journal of Pharmacy and Pharmaceutical Sciences, 2013; 2: 2097-2117.
7. Aaranowsky J, Klose P, Musial F, Haeuser W, Dobos G, Langhorst J. Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia. Rheumatol Int 2009;30:1–21.

The truth is nobody is doing a very good job with chronic pain. I now use a biopsychosocial approach. I use relaxation, exercise advice (graded activity/ exposure), examine beliefs (which tend to be catastrophic), behaviours (which are often fear avoidant) and use encouraging/ hopeful messages for positive change. You need to look at sleep hygiene and basic dietary advice. I have the luxury of time that doctors often don't, but for too long there has been a biomedical approach to pain that simply ignores the new understanding of pain neuroscience.

It should be also noted that most orthopaedic operations for chronic pain that have been tested do not outperform placebo and that the biggest reason for positive outcomes appears to be the "therapeutic alliance", the ability of the clinician to allow the patient to tell their story, to form a trusting, compassionate relationship and to create agreed actionable goals for change based on values. If every clinician got these basics right we would see a marked decline in chronic pain suffering.

Chronic pain sufferers are frightened by the medical system (MRIs being abnormal in almost everyone including those without pain). I believe a lot of pain is iatrogenic.

Like a previous comment, I am very upset that hypnosis still isn't getting the recognition it deserves. It is simply not acceptable to have such a powerful and truly side effect free treatment not being utilised by the NHS when there is such a wealth of evidence, especially for central sensitization and neuropathic pain.

The first rule of practising evidence-based Medicine is: read the evidence. The respondent below seems to have read a different article in declaiming all these treatments to be useless and dangerous, while under the impression that harms from western Medicine are axiomatically fewer. The lack of discrimination in criticism between any of the different modalities of treatments while branding them all a dangerous threat is also not very convincing.

The article describes a significant body of clinically meaningful RCT evidence - including inflammatory markers - finding that acupuncture may be as effective as DMARDS and may add benefit to DMARD treatment in patients with Rheumatoid Arthritis.
The article also describes a body of relevant evidence of benefit of acupuncture for chronic low back pain. As a USA Orthopaedic surgeon, Steven Zeitzew would know that; "The clinical practice guideline provided by the American College of Physicians and the American Pain Society recommends acupuncture as a non-drug therapy for CLBP patients.".

The harms of acupuncture suggested by the evidence are of the order 0.13%-0.14% for minor adverse events, with no serious adverse events in trials of 31,000 and 35,000 patients. Rather safer than NSAIDs, then.

As a family doctor who practises osteopathy free of charge in the NHS, I was disappointed not to see any mention in the article of the high quality RCTs showing significant clinical benefits of osteopathy, over and above exercise/physio. I have the advantage of continuity of care to know that these patients really do benefit substantially directly from osteopathic treatment, in all of the measures - pain, function, use of analgesics, employment/disability, referrals and reduction in surgery - which one would consider as important outcomes. The positive cost-effectiveness analysis of the UK BEAM trial has been published, so it is a shame to see that the recommendations for manual therapy have been weakened in the revised NICE guideline for back pain. Osteopathy is also safer than NSAIDs.

Where evidence is weak or conflicted, it is sensible to adopt equipoise and learn to tolerate uncertainty while further, better-targeted research evidence is allowed to emerge. Thanks to BMJ for publishing this interesting evidence review, I would recommend contributors read it.