COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PALLIATIVE CARE

1. COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PALLIATIVE CARE Michael Marschke, MD Medical Director of Horizon Hospice

2. Objectives • Understand the various alternative therapies to palliative care including: • Local measures • Physical modalities • Mind-focusing techniques • Energy work • Internal agents • Learn when to recommend CAM therapies and when to avoid them

3. CASE SCENARIO Mr. B is a 46yo self-employed computer processor who comes into your office with a 6 month history of progressive mid- to low-back pain. His pain is worse after sitting at the computer or after long car rides, and better in the morning, though he is stiff. He never has exercised much but is not obese, and in fact has been losing weight recently without trying. This pain has affected his ability to work over 2 hours straight at his computer. Over the last month he has noted a radiating, sharp pain down the back of both legs with numbness in the back of his right leg. This pain has affected his life so much he is now depressed, losing income, and it is affecting his marriage and sex life.

4. On exam, he is in obvious pain walking into your office, unable to sit down. He has para-lumbar muscle tightness and mild tenderness with marked decrease ROM diffusely in his whole spine, with a positive straight-leg raise at 20degrees on the right. His neuro exam and rest of his exam is benign. Plain X-rays reveal lytic lesions in the lumbar spine. Further work-up revealed a lung mass, biopsy proven to be adenocarcinoma of the lung with wide-spread mets to the bone. There was no spinal cord compression on MRI. Now faced with this life-threatening disease, he went into a deeper depression, though he wanted to undergo chemotherapy and radiation, which he did begin. Narcotics were started, though he never wanted to take a lot of these while he tried to keep up his work. He is willing to try anything to help with his comfort.

5. CASE SCENARIO • What factors are playing a role in Mr. B’s pain control? • What non-pharmacologic therapies could be useful in this patient?

6. MULTIPLE FACTORS TEND TO CONTRIBUTE TO THE CHRONIC PAIN EXPERIENCE • Somatic/neuropathic pain – with lytic lesions in spine and sciatic nerve impingement • Psychologic input – depression and other conditions can worsen pain. • Socioeconomic input – pain’s impact on a person’s work and income can play large factors. • Other psychosocial and spiritual factors can play a role.

7. CAM Adjuvants for Somatic/Neuropathic Pain LOCAL TOPICAL MEASURES: • Heat or ice – patient dependent; if tightness heat may help; if swelling ice may help more. • Ben-Gay, Icy Hot – combo of menthol, salicylates to affect local inflammatory paths and increase vascularity to the area • Capsaicin cream – a derivative of red peppers found after repeated use to wear out substance P in pain receptors, though can burn the first few days and needs to use it often • Mild relief at best

8. CAM Adjuvants for Somatic/Neuropathic Pain PHYSICAL MODALITIES: • Physical therapy, occupational therapy • TENS/PENS units – transcutaneous or percutaneous electrical nerve stimulators stimulate larger pain fibers to gate/inhibit the painful spinal smaller delta and C nerves at the spine • Chiropractic or osteopathic manipulation – be careful with long-lever manipulations when there is nerve impingement • Exercise, yoga, Tai chi • Massage therapy • Acupuncture • All probably equally effective in chronic low back pain

9. CAM Adjuvants for Somatic/neuropathic Pain MIND-FOCUSING TECHNIQUES • Meditation, guided imagery – various forms used to decrease stress and focus mind on pleasing things • Art/music therapy, including humor • Pet therapy • Hypnosis – recognized 40 yrs ago by AMA as a validated therapy in psychology, discovered in 1800s by Frank Mesmer; focuses the mind and increases suggestibility; proven even in children • Biofeedback – using nerve and muscle sensors to help the mind relax certain parts of the body reducing muscle tightness and pain • All could be useful for depression along with pain; no risks involved at all

10. CAM Adjuvants for Somatic/neuropathic Pain ENERGY TECHNIQUES: • Healing touch – used by many RNs to focus energy fields; developed by an RN in 1989 • Reiki – roots in ancient healings of Tibet; using less than the pressure of a penny on the skin to help energy flow • Reflexology – roots from Chinese and Egyptian traditions; different points on the hands and body reflexly effect other parts of the body • All need research to validate; but risk free

11. CASE SCENARIO Mr. Z is a 60yo Hispanic gentleman with pancreatic cancer. He was diagnosed 3 months ago when he came in with weight loss and epigastric pain. He was found to have liver mets on CT scan and he elected palliative care and home hospice. He does have recurring pain but never complains a lot about it. He has difficulty eating without nausea and vomiting. His pain has never been severe; it is mainly the vomiting that is causing him suffering. On social history he has a large family and they are economically challenged. He was always the bread-winner and now that he cannot work he is very anxious about his family and worried that he will be a burden to them.

12. Mr. Z is deeply religious, but now anxious about the after-life. On exam, he is in no obvious pain, but jaundiced, and cachectic. Other significant findings just include a mildly enlarged liver and tenderness in his epigastrum. Though reluctant to take medications, he is willing to try other measures to help his pain, especially since herbs and other alternative therapies are familiar to him and his family culture.

13. CASE SCENARIO • What factors are playing a role in Mr. Z’s nausea? • What non-pharmacologic therapies could be useful in this patient?

14. MULTIPLE FACTORS CAN PLAYA ROLE WITH NAUSEA • Physical problems – liver/pancreatic tumors; obstruction; medication • Psychologic problems – anxiety • Spiritual suffering and anxiety

15. CAM Adjuvants for Nausea/vomiting INTERNAL AGENTS: • Herbs – basis behind many modern medicines; chamomile, peppermint, cola, ginger, cannibis and others useful for nausea; beware of formulations • Flower essences – very diluted mixtures of flower parts in water used to alleviate symptoms – research needed; very safe though • Homeopathy – extremely dilute substances that in higher doses cause the symptom but in these microscopic doses alleviate symptom; very safe but research needed

16. CAM Adjuvants for Nausea/vomiting EXTERNAL/PHYSICAL MODALITIES: • Acupuncture proven in research to help alleviate nausea • Aromatherapy – uses the essential oils of plants to create smells that do affect the limbic system and many like peppermint, basel, and lavender; totally safe

17. CAM Adjuvants for Nausea/vomiting MIND-FOCUSING/ENERGY TECHNIQUES: • Healing touch has been used successfully in case reports with some patients • Meditation, guided imagery, hypnosis, art/ music therapy can all help with anxiety and alleviate this man’s nausea

18. CASE SCENARIO Ms. C is a 76yo woman with extensive end-stage breast cancer, originally diagnosed 2 years ago. Now she has tumors in her lung with recurrent pleural effusions that have been tapped many times and are now loculated. She has exhausted all chemotherapy and radiation therapy and is entering hospice. She has no pain but suffers from recurrent dyspnea. She is dependent on oxygen, and still has a difficult time walking or lying flat without getting acutely short of breath. She has become very dependent on others. This situation has created much anxiety in her life.

19. CASE SCENARIO She is used to living alone and now has a caregiver 6 hrs a day. She does get afraid at night – not afraid to die, but afraid to be short of breath. On exam, Ms. C. is out of breath. She is cachectic, has edema mildly in both legs, decreased breath sounds with dullness just at the bases of both lungs. She is on diuretics, occasionally takes Ativan which does help, but reluctant to take morphine because it makes her too sleepy.

20. CASE SCENARIO • What factors are playing a role in Ms. C’s symptoms? • What non-pharmacologic therapies could be useful in this patient?

21. CAM Adjuvants for Dyspnea INTERNAL AGENTS: • Herbs – there are many that relief congestion and improve respiratory function • Flower essences – some can relieve congestion and improve anxiety with dyspnea • Homeopathy – many different kinds have been tried to help patients with dyspnea

22. CAM Adjuvants for Dyspnea EXTERNAL/PHYSICAL MODALITIES: • Aromatherapy like eucalyptus or lavender can open up air passages to aid breathing • Massage therapy has been shown to be useful to relax the body and improve breathing • Acupuncture may be useful in some • Healing touch has been used • Mind-focusing techniques may be useful especially with lot of fears

23. CAM FACTS • 30-50% of the population use CAM, spending billions of dollars • Many of the therapies have been around for centuries and used with excellent results; but have remained outside of researched modern biomedical technologies • Recently though, National Center for CAM at the NIH set up to research this field • Many are becoming licensed and regulated

24. CAM FACTS • Less than 10% of the time will physicians know the CAM therapies their patients are using • Most are very safe • Beware of potential interactions with agents taken internally • Beware of what is in the products, especially herbs – now 2 independent agencies are researching products in US – USP and Consumer Labs will have quality labels on products they approve; many German products have been well researched

27. CAM FACTS • Other risks – acupuncture may cause bleeding, rare pneumothorax - chiropractic manipulations should be avoided with neck osteoarthritis and nerve impingement - beware of avoidance of proven medical therapies because of CAM

28. CAM RESOURCES • PDR for herbals and dietary supplements • Alternative Medicine Alert, by Thomson American Health Consultants, at www.ahcpub.com, critically reviews the literature on various CAM therapies • Consumerlab.com • MayoClinic.com • USP dietary supplement verification program at uspverified.org • Center for Alternative Medicine Research in Cancer at the U of Texas – Houston at mdanderson.org • National Center for CAM at nccam.nih.gov and altmed.od.nih.gov