COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PAIN CONTROL

1. COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PAIN CONTROL Michael Marschke, MD Medical Director of Horizon Hospice Clinical Instructor of Medicine At Northwestern Univ.

2. OBJECTIVES • Using case scenarios, understand the uses of different Complementary and Alternative Treatments in various pain syndromes. • Beware of potential risks with CAM. • Provide preliminary data from Horizon Hospice’s comprehensive CAM program

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 • Physiologic pain – somatic/neuropathic pain • 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 • Chiropractic or osteopathic manipulation – be careful with manipulations when there is nerve impingement • Exercise, yoga, Tai chi • Massage therapy • Acupuncture • TENS/PENS units – transcutaneous or percutaneous electrical nerve stimulators – stimulate larger pain fibers to inhibit the spinal smaller delta and C pain pathways • 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 suggestiblity; 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

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 pressure points on the hands, feet, and body reflexly effect other parts of the body • All need research to validate

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. Currently, he does have recurring crampy abdomenal pain that has caused difficulty eating and occasional nausea with vomiting. Narcotics do help but make him so drowsy he is reluctant to use them alot. 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 presently, 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 pain? • What non-pharmacologic therapies could be useful in this patient?

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

15. CAM Adjuvants for Visceral Discomforts INTERNAL AGENTS: • Herbs – basis behind many modern medicines; chamomile, peppermint, cola, ginger, cannibis and others useful for stomach cramps and 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 Visceral Discomforts 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, basil, and lavender can help nausea, cramps; totally safe unless sensitive to smells

17. CAM Adjuvants for Visceral Discomforts 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 may alleviate these symptoms • Biofeedback can also help with colicky discomforts especially with anxiety

18. 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

19. 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

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

21. HORIZON HOSPICESCAM PROGRAM RESULTS • Horizon started a multi-faceted CAM program in 2002 for its patients. • Can provide massage, healing touch, herbs, flower essences, aromatherapy, acupuncture, art therapy, pet therapy, meditation, homeopathy, neuro-emotional technique, music therapy to interested patients • Over the first 6 months, there were 80 treatments for 27 patients. 21 of the patients asked to receive massage therapy. The others received healing touch, aromatherapy, NET, and meditation.

22. HORIZON HOSPICESCAM PROGRAM RESULTS • Just over 50% received CAM for relief of pain; about 30% for anxiety, 25% for fatigue/depression. • Immediately after the treatment, patients rated the effectiveness of the treatment on a -3 to +3 Likert scale – all patients gave it a positive rating, with an average of +2.1 for massage and +2.0 for the others.

25. HORIZON HOSPICESCAM PROGRAM RESULTS • All patients who received CAM treatment gave positive descriptors about the experience, with the majority feeling more relaxed and peaceful. • The effects tended to last about a day, though many looked forward to their next treatment. • One patient was able to get off of high dose Fentanyl patches with healing touch; another used 75% less breakthrough medication the day she received massage. • A wife of one of our patients was able to be taught some massage, and this greatly improved her ability to touch her terminal husband again without being afraid.

26. CAM RESOURCES • PDR for herbals and dietary supplements • Consumerlab.com • MayoClinic.com • USP dietary supplement verification program at usp-dsvp.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 • Alternative Medicine Alert, published monthly newsletter by American Health Consultants, info at ahcpub.com