Chronic Pain: an Integrative Approach to Effective Pain Management

CHRONIC PAIN: AN INTEGRATIVE APPROACH TO EFFECTIVE PAIN MANAGEMENT

COURSE DESCRIPTION

Pain is a universal experience for virtually every human being and is an indication that something is wrong. Pain interferes with the enjoyment of life. It makes it difficult to work, socialize with friends and family, sleep, and accomplish activities of daily living. It may reduce productivity and create financial hardships in terms of lost work and high medical bills. Chronic pain can lead to a loss of appetite, depression, and many other physical and psychological consequences as well as a loss of the joy of life.

The outcome of this course is for the learner to describe the scope of chronic pain, key historical events in pain management, the physiology of pain, types of pain, conventional pharmacological treatments for pain, and integrative approaches to pain management.

COURSE OBJECTIVES

Upon completion of this course, you will be able to do the following:

1. Describe the scope of pain and chronic pain in the United States. 2. Identify key events in the history of pain management. 3. Define pain and chronic pain. 4. Explain the physiology of pain. 5. Describe the types of pain. 6. Identify various pain behaviors. 7. Compare and contrast the various pharmacological methods for managing pain. 8. Compare and contrast the various integrative therapies useful in pain management.

INTRODUCTION

Pain interferes with virtually every aspect of life—sleep, work, socializing with family and friends, hobbies, and activities of daily living. Pain is associated with injuries and disease. Sometimes pain is the cause of the disease (such as in headaches or neuropathic pain) and sometimes it occurs as a result of a specific condition (such as postoperative pain). Millions of people suffer from pain. It exacts a tremendous cost on our country in terms of health care costs, rehabilitation and lost worker productivity, as well as emotional and financial burdens for patients, families, and society. Consider these sobering statistics (American Academy of Pain Medicine, 2014; Cloud, 2011; Hart, 2010; National Center for Complementary and Integrative Health [NCCIH], 2017b; Suddath, 2011):

 Pain affects more Americans than diabetes, heart disease, and cancer combined. Over 100 million people suffer from pain, compared to 24 million people with diabetes, 23 million with heart disease, and 11 million with cancer. Most pain sufferers are women.

 The annual cost of chronic pain in the United States, including health care expenses, lost income, and lost productivity, is estimated to be between $560 billion and $635 billion.

 More than half of all hospitalized patients experience pain in the last days of their lives. Yet, while there are therapies available to alleviate pain, among those

dying of cancer, for example, 50% to 75% of patients die in moderate to severe pain.

 An estimated 20% of Americans report that pain or physical discomfort disrupts their sleep a few nights a week or more.

 The most common types of pain are low-back pain, severe headaches or migraine pain, neck pain, and facial pain.

 Back pain is the leading cause of disability in Americans under 45 years of age.

 More than 50% of individuals experiencing pain feel they have little or no control over their pain.

 Almost two thirds of individuals report that pain impacts their overall enjoyment of life and more than 75% report feeling depressed, 70% say they have trouble concentrating, and 74% say their energy level is impacted.

 Most pain sufferers have been to their family physician for assistance and almost half have been to a specialist (such as an orthopedist).

 There are an estimated 8,000 pain specialists in the United States—one physician for every 9,500 chronic pain sufferers. This is not nearly enough to address the need in this country.

 The most common reason cited for seeking complementary and alternative medicine (CAM) and integrative therapies was pain.

o More than 8% of Americans have received a massage in the past year, usually for back or neck pain. o Approximately 11% of Americans have used meditation or deep-breathing exercises for physical and emotional pain. o Approximately 1.4% of Americans have experienced acupuncture.

The citizens of the United States are not unique in struggle with pain. The World Health Organization (WHO) states that one in five people globally suffer from moderate to severe chronic pain and one in three are unable or less able to maintain an independent lifestyle due to their pain (World Health Organization, 2004). Chronic pain is emerging as an important component of the global burden of disability (Croft, Blyth, & van der Windt, 2010).

One of the most effective means of managing pain is to become educated about its causes and the wide variety of possible conventional and integrative therapies available to treat pain. Both consumers and healthcare providers must have a solid understanding about the causes of and treatments available for pain to effectively and compassionately address their concerns.

THE HISTORY OF PAIN RELIEF

Human beings have suffered from pain for as long as they have existed. It is the oldest medical problem and universal affliction of humankind. But little about it has been

© ALLEGRA Learning Solutions, LLC All Rights Reserved clearly understood until recently. Religion, politics, and philosophical perspectives defined the meaning of pain for individuals for much of human history (Meldrum, 2003).

The Greek goddess of revenge, Poine, gave us the word “pain.” According to mythology, she was sent to punish mortals who had angered the gods. This irony is clear to individuals who often feel that the suffering they experience as a result of their pain is a kind of divine vengeance (Lallanilla, 2005).

Attempts to relieve pain have ranged from the bizarre to the visionary. The following timeline provides an overview of the key events in the history of man’s attempt to relieve pain (Lallanilla, 2005; NCCIH, 2015; Park, 2011; Suddath, 2011; Cloud, 2011):

 The Neolithic Age (approximately 10,000 B.C.)—trepanning, early acupuncture, and other methods were used.

o A trepanning procedure involved boring a hole in the skull to relieve pressure and pain and to free the spirits. It was used by many ancient cultures throughout the world. o Early acupuncture involved using pieces of polished or flat stones that were placed in strategic parts of the body. By the 2nd century, the stone needles were replaced by metal needles. o Votive offerings and sacrificial animals were used to carry the sins of people out into the wilderness and thus relieve their pain. o Rattles, gongs, and other noisy devices were used to frighten painful devils out of a person’s body in an attempt to relieve pain. o Native American healers sucked on pain pipes held against a person’s skin to “pull” out the pain or disease.

 3300 B.C.—Tattoos may have been used on certain body parts (such as the spine, knee, or ankle) to relieve pain.

 2750 B.C.—Eels were used by the ancient Egyptians to produce pain-relieving shocks. The eels were laid over the wounds. This technique is considered a precursor to the modern transcutaneous electrical nerve stimulation (TENS).

 100 A.D.—Romans used hot seawater baths and ointments that contained poppies (containing a form of opium) and wild cucumber to relieve pain. The Greek physician, Hippocrates, used willow bark and leaves to relieve pain and he told women in childbirth to chew them. The willow plant, a member of the plant genus Salix, contains a form of salicylic acid—the active ingredient in aspirin.

 400-500 A.D.—The Middle Ages saw a generous use of herbs. Polypharmacy was widely used and one popular concoction was theriac—a honey-based compound with approximately 64 other compounds in it.

 1200 A.D.—Practitioners used a somniferous sponge during surgery to relieve pain. The sponge was steeped in a mixture of opium and herbs.

 1774—Franz Mesmer, a German physician, began treating pain with magnets and “mesmerism” (a hypnotic technique). His theories were later debunked but certain aspects of his treatment remain today in modern hypnotherapy.

 1846—William T. G. Morton, a dentist, used ether anesthesia for the first time at Massachusetts General Hospital when he removed a tumor from a patient during surgery. A short time later, the term “anesthesia” was coined by Oliver Wendell Holmes, Sr. Prior to that time, choking people with carotid compression or holding peoples’ faces over a gas stove until they passed out were other, rather bizarre techniques used to provide a form of anesthesia for surgery.

 1853—Queen Victoria popularized the use of chloroform in childbirth when she successfully used it to deliver her eighth child, Prince Leopold. Chloroform had previously been considered controversial on religious and safety grounds.

 1886—John Pemberton (a Georgia pharmacist) invented Coco-Cola. It contained cocoa leaves, which are the source of cocaine. The drink was marketed as a remedy for all types of ailments, especially headaches.

 1899—Bayer introduced the “drug of the century”—aspirin—to the market.

 Early 1800s and 1900s—Magnets were used by many healers for their purported healing properties. In addition, a variety of other techniques such as electricity, wet plaster made from hot mustard, balms, liniments that were said to have contained magnetic properties, remedies with varying quantities of opiates, alcohol, and cocaine were also available.

 Early 1900s—Physicians used gold salts injected into limbs to treat arthritis.

 1951—Fernand Lamaze, a French obstetrician, observed the use of natural birthing techniques using psychoprophylaxis while on a visit to Russia. He would later popularize this technique and its breathing and relaxation component as the “Lamaze method” of childbirth.

 1960s and 1970s—Tylenol® and Motrin® were introduced to the American drug market as over-the-counter (OTC) methods of pain relief.

 1971—Journalist James Reston was visiting China as part of a delegation covering the historic visit of President Richard Nixon. He received acupuncture at a hospital in Beijing. He later wrote an article about the treatment and is largely credited with popularizing its use in the Western part of the world.

 1974—The modern transcutaneous electrical nerve stimulation (TENS) machine was patented, helping many sufferers of chronic and acute pain find relief.

 1991—The U.S government established the National Center for Complementary and Alternative Medicine (NCCAM) (now called the National Center for Complementary and Integrative Health [NCCIH]) to study healthcare systems, practices, and products that are not part of conventional medicine.

 2010—A Stanford Medical School study suggested that love can be an effective painkiller—as effective as pharmaceuticals or illicit drugs.

PAIN DEFINED

Pain is one of the body’s most primitive signals and is essential to survival. It is felt by the most advanced as well as the most primitive of creatures. Pain tells a person to avoid danger and stay away from predators (human or otherwise). Pain is protective and is a sensation that most humans and animals seek to avoid. It tells us we have been cut, burned, hurt, broken, and harmed. “Pain is the human bodyguard, the cop on the beat racing to the scene, sirens wailing, shutting down traffic” (Park, 2011, p. 64).

Pain is a completely subjective experience and is defined in a number of ways (Meiner, 2010).

 It is a warning signal from the body that an injury has occurred.  It is an unpleasant sensory experience associated with actual or potential tissue damage.  It is a physiologic response to an injury and it is associated with emotional responses to the sensation.

The definition most clinicians now use is that “pain is whatever the person experiencing it says it is, and it occurs when that person says it does” (Urden, Stacy, & Lough, 2014, p. 144).

Most of the literature supports the concept that pain is a complex phenomenon derived from sensory stimuli or neurologic injury and it is modified by the individual’s memory, expectations, and emotions. Pain is usually associated with some injury or pathophysiologic process but it is clearly individual (Meiner, 2010).

The self-report of pain by a client should be considered sufficient evidence to establish pain as a diagnosis. The patient, not the healthcare provider, is the authority on the pain (American Pain Society, 2006).

Vital signs and observed behavior should not be used instead of a self-report of pain unless the patient is unable to communicate effectively. The cornerstone of an assessment of pain is the acceptance by the healthcare provider that the pain belongs to the patient or client.

CHRONIC PAIN

What happens when pain “goes rogue” and sends off signals that are actually false alarms? What occurs when pain is no longer adaptive? This is what happens with chronic pain (Park, 2011). “Rather than saving lives, it wrecks them. The result: persistent, unceasing torment” (Park, 2011, p. 64).

While acute pain has a sudden onset, is short lived, transient, and is usually treated with medications for a short duration, chronic pain is defined as any pain lasting longer than 12 weeks (NCCIH, 2017b). Chronic pain affects millions of Americans. It may appear for days or weeks at a time and then dissipate, only to return. Chronic pain may be caused by a disease (such as fibromyalgia) or a life situation (stress), or the cause may be idiopathic, or unknown (Park, 2011). © ALLEGRA Learning Solutions, LLC All Rights Reserved

Chronic pain is the most common reason for patients to seek medical care (Teets, Dahmer, & Scott, 2010). Approximately 10% of patients who have surgery (even routine surgery) and 20% of cancer patients will never be the same after their treatments, and the pain they suffer may extend from the original site (if it is from surgery, for example) or it may be present in many parts of the body (Park, 2011).

Common causes of chronic pain include low-back pain, headache, arthritis pain, pain from nerve damage, cancer pain, and other conditions, such as fibromyalgia, in which pain is a significant factor. Individuals with chronic pain often have two or more co- existing related conditions such as chronic fatigue syndrome, endometriosis, inflammatory bowel disease, interstitial cystitis (painful bladder syndrome), temporomandibular joint dysfunction, or vulvodynia (chronic vulvar pain). Whether these disorders share a common cause is not currently known (NCCIH, 2017b).

The cause of chronic pain is generally very complex and multifactorial. Sometimes it is the nerve itself that is damaged. It continues to send pain signals long after the original injury has healed or it may send pain signals even when there was no injury. Before the 1960s, scientists believed that the pathways to the brain were predetermined (the “neural highway”). Now, however, research has shown that the routes are flexible and a damaged nerve can affect those around it, thus changing the pathways. If the brain feels pain for a long enough period of time, the brain will actually be changed. The emotional part of the brain is also affected (Suddath, 2011).

Brain-imaging studies as well as genetic and molecular biology research are also suggesting that the brain of a person with chronic pain looks and behaves differently than a normal brain. In addition, these studies also suggest that the process is circular—that is, the abnormal circuitry of the chronic pain brain causes it to register pain, which in turn leads to changes in that brain. Individuals with chronic pain have been shown to have lower levels of endorphins compared to those who do not suffer

© ALLEGRA Learning Solutions, LLC All Rights Reserved from chronic pain. There may be inherited differences in the number, type, and intensity of pain receptors and in the body’s ability to control pain. This research provides exciting opportunities to develop methods of treating chronic pain more effectively or even eliminating it altogether (Park, 2011).

In addition, chronic pain can be self-perpetuating and so the sooner it is addressed, the less likely it will be to cause persistent and relentless pain. Patients often try many management options with no success. They may also seek the advice and support of their healthcare provider. Despite these efforts, approximately 80% of patients never receive effective treatment for their pain (Park, 2011). This may be due to the fact that, while many chronic pain patients consider pain a disease in itself, healthcare providers have only recently recognized this (Park, 2011). “Chronic pain really is a disease of the central nervous system. It affects the sensory, emotional, motivation, and cognitive pathways” (Park, 2011, p. 71).

In 2000, partially in recognition of the importance of treating pain early and effectively, pain was included in patient assessments as the fifth vital sign, as important as blood pressure, pulse, temperature, and respiratory rate (State of California, Department of Consumer Affairs, 2000).

However, as of 2016, the American Medical Association (AMA) recommended that pain be removed as the fifth vital sign in professional medical standards because its membership believes that physicians have played a key role in the opioid epidemic by overprescribing, misusing, and diverting pain medications and now must do their part to help end the epidemic. Critics say this recommendation will make it even more difficult for individuals suffering from pain to receive proper pain assessments and treatment. The AMA is also lobbying the Joint Commission to weaken its pain management standards, calling for a resolution for greater access to naloxone (a drug that reverses the effect of opioid overdose), and is adopting a policy urging health insurers to increase coverage of nonopioid and nonpharmacological pain treatments (Anson, 2016).

Currently the Joint Commission does not endorse pain as a vital sign and does not require pain assessment for all patients. It only states that pain should be assessed (and reassessed) in all patients in a manner that is consistent with the patient’s age, condition, and ability to understand (The Joint Commission, 2016).

Patients and healthcare providers alike are frustrated with the ineffective understanding and treatment of chronic pain. The Institutes of Medicine (IOM)—the independent scientific advisory arm of the National Academies—is developing a report on the need to treat chronic pain as a disease of both the mind and the body rather than a symptom that needs to be managed. This is an enormous paradigm shift in the way pain is viewed by the healthcare community (Park, 2011).

Integrative health (IH) approaches can offer a more comprehensive treatment approach for patients with chronic pain. Their use elicits a broader perspective of the individual’s

PHYSIOLOGY OF PAIN

The nervous system contains millions of nerve endings, and pain activates these endings. Nociceptors are the specific and specialized nerve endings responsible for pain. Pain is a protective mechanism and thus the nerve endings do not adapt to repeated painful stimuli. Instead, repeated stimulation actually heightens sensitivity to the stimuli. Nociceptors are found in many organs in the body including the skin, joints, muscle, fascia, viscera, and smooth muscle of the arterial walls. Nociceptors are found in the afferent pathways, terminate in the spinal cord, and are activated by thermal, mechanical, and chemical stimuli (Meiner, 2010).

There are three major components of the nervous system that cause the sensation and perception of pain (Meiner, 2010; Urden, Stacy, & Lough, 2014):

1. Afferent pathways (reception) 2. Central nervous system (perception) 3. Efferent pathways (reaction)

A very basic, introductory explanation of pain physiology follows (Meiner, 2010):

 When a painful stimulus (such as a burn or pinprick) occurs (“reception”), an impulse is sent to a nociceptor along a peripheral sensory (afferent) nerve fiber that enters the gray matter of the spinal cord.

 Evaluation and interpretation of the stimulus occurs in the gray matter of the cord, and neurotransmitters facilitate the transmission of the stimulus from the peripheral neuron up to the cerebral cortex of the brain.

 The brain interprets the quality of the pain (“perception”) and the body responds (“reaction”) in a way that integrates past experiences with pain, knowledge of pain, and cultural associations with pain.

 The interpretation is relayed back through the peripheral nervous system (efferent) pathways and the pain is sensed and perceived.

Two types of fibers transmit painful stimuli from the injury site through neural pathways (Urden, Stacy, & Lough, 2014):

1. A fibers—These are thinly myelinated fibers located in the skin and cutaneous tissue. (Myelin is a fatty white substance surrounding the nerve cell, acting as insulation.) These fibers rapidly transmit mechanical and thermal pain that is easily localized and which the individual may describe as “sharp,” “prickling,” “electric,” or “acute.”

2. C fibers—These are unmyelinated fibers located in the subcutaneous tissue, fascia, tendons, joints, ligaments, and muscles. They slowly transmit mechanical, thermal, or chemical pain that is difficult to localize and which the individual may describe as “throbbing,” “aching,” “burning,” “gnawing,” or “chronic.”

Human beings (and animals) of all ages feel pain—including infants. Infants can experience chronic pain, especially when they have been born prematurely, or have a disease for which surgeries or painful testing procedures must be undertaken. With aging, there is some loss of nerve cells or their dendrite connections but no change in sensitivity to pain. In addition, as we age, we may experience the following:

 An increase in connective tissue that affects cardiovascular and musculoskeletal tissue  A decrease in basal metabolic rate  A decrease in hepatic efficiency and blood flow  A decrease in kidney perfusion  A slower gastrointestinal transit time  Atrophy of the gastric glands and decreased secretion of digestive enzymes  A decrease in immune response  A decrease in body mass and water volume that affects nutrition, metabolism, and the pharmacokinetic activity of drugs  A decrease in the number of drug receptors and less affinity for drugs at the receptor sites

These changes may affect drug sensitivity and emphasize the need for healthcare professionals to be especially aware of the possible effects of pain treatment on the aging adult.

TYPES OF PAIN

Although all pain uses the same nociceptors, the type of pain a person experiences is classified by the location of the fibers that are sensitized.

There are four types of pain (American Pain Society, 2006; Meiner, 2010):

1. Nociceptive pain—This type of pain can be visceral or somatic. It often arises from tissue inflammation, mechanical deformation, ongoing injury, or destruction of tissue. It responds well to common analgesic medications and nonpharmacologic strategies. The pain can be sharp, dull, or aching and can be well localized or diffuse. It can be felt in the skin, muscles, tendons, joints, bones, or visceral organs.

Examples of this type of pain include:  Pain from a broken leg  Sunburn  Chemical burn  Appendicitis  Colic  Rheumatoid arthritis  Osteoarthritis  Skin and mucosal ulcerations

 Visceral pain (pain of internal organs and viscera)

2. Neuropathic pain—This type of pain results from pathophysiologic processes involving the peripheral or central nervous system. This type of pain does not respond predictably to analgesic therapy such as opioids or nonsteroidal anti- inflammatory drugs (NSAIDs). It does respond to unconventional analgesic drugs, such as tricyclic antidepressants, anticonvulsants, or antiarrhythmic drugs. This type of pain is often described as having a burning or electrical quality that feels like a shock or lightning bolt.

Examples of this type of pain include:  Painful diabetic polyneuropathy  Poststroke pain  Trauma (e.g., spinal cord injury)  Postamputation pain (from trauma or surgeries such as mastectomies)  Postherpetic or trigeminal neuralgia

3. Mixed or unspecified pain—This type of pain has a mixed or unknown mechanism. The treatment is unpredictable and may require different or combined approaches to be effective. An example of this type of pain is a headache.

4. Psychologically based pain syndromes can include somatization disorders, hysterical reactions, or other rare conditions. Persons with this type of disorder may benefit from specific psychiatric treatments but traditional medical interventions for analgesia are not usually indicated.

PAIN BEHAVIORS

Health care providers have been taught that, with pain, clients will exhibit visible physiologic and behavioral signs of distress and that these signs form the basis for pain assessment. These signs include the following (American Pain Society, 2006):

 Elevated blood pressure  Tachycardia  Tachypnea  Dilated pupils  Retention of secretions  Hypercoagulation (a tendency for excessive blood clotting)  Muscle spasm  Delayed gastric and bowel function  Structural changes and malfunction of the nervous system  Grimacing  Moaning

 Agitation  Restlessness  Sweating  Withdrawal movements when repositioning  Guarded posturing  Social avoidance behavior  Fatigue  Abnormal release of hormones that affect urine output, fluid volume, and electrolyte balance  Anorexia

However, because of adaptations to pain and cultural factors, the lack of visible signs of pain does not mean a lack of pain.

In addition, pain behaviors in a cognitively impaired adult may include the above behaviors as well as those behaviors that are different from the normal behavior of that individual (e.g., the quiet person becomes talkative).

When pain results from a tissue injury during surgery, an acute pain response is stimulated. Stress hormones are released, tissue breakdown begins, the metabolic rate increases, blood clots, fluid is retained, and the immune response is impaired. Energy is diverted to these body responses and, therefore, less energy is available for healing. Tissues can become more sensitized by local inflammatory substances released from injured cells, and acute pain at the site of the injury results. The central nervous system is then sensitized and subsequent pain responses are improved. Untreated, this can result in chronic or persistent pain. Called the “wind-up phenomenon,” it starts at the skin and can result in (Gudin, 2004)

 a buildup of some neurotransmitters to toxic levels,

 an increase in spontaneous nerve discharges,  recruitment of silent receptors for pain transmission,  an expansion of the painful area, and  a lowered threshold for pain stimuli.

If chronic pain persists, the client can experience depression, weight loss, shock, delayed gastric emptying, constipation, weakness, infection, electrolyte imbalances, sleep disturbances, and impaired mobility. The individual can become socially withdrawn, use more healthcare services, suffer from malnutrition, and experience gait disturbances or falls. Among people of all ages with chronic pain, 40% to 50% suffer from depression and suffer greater pain. This vicious cycle makes them less able to cope with stressors, including pain, and requires that both the pain and the underlying mental state be treated concurrently (American Pain Society, 2006).

PHARMACOLOGIC MANAGEMENT OF PAIN

The pharmacologic management of pain involves an infinite number of options. This section does not provide an in-depth discussion of pharmacology for chronic pain patients but will provide an overview of the most commonly administered medications in the treatment of pain. The healthcare provider is encouraged to consult a detailed pain management or pharmacology resource for comprehensive information about this topic.

The World Health Organization (WHO) suggested a three-step analgesic ladder as a basis for pain management (Perron & Schonwetter, 2001; WHO, 2017)

Step 1—Mild Pain: nonopioid +/- adjuvant

Step 2—Mild to Moderate Pain: weaker opioid for mild to moderate pain +/- nonopioid, +/- adjuvant

Step 3—Moderate to Severe Pain: stronger opioid for moderate to severe pain +/- nonopioid +/- adjuvant

In addition, the following recommendations provide the best pain relief when pharmaceuticals are being used (Perron & Schonwetter, 2001; WHO, 2017):

1. Give medicines by mouth—Oral administration is the most effective and the least expensive method of medicating clients. Oral medications can be easily titrated and thus the oral route of administration is preferred.

2. Give medications around the clock—Pain medication should be administered throughout the day by routine administration or sustained release preparations.

3. Give medications according to the WHO ladder—This procedure provides maximum relief of pain.

4. Give medications on an individual basis—Treat each client individually, and adjust dosages or interventions in order to obtain the most effective relief.

5. Pay attention to detail—Closely monitor clients to determine the effectiveness of the intervention and determine if any side effects are present.

Categories of Pharmacologic Agents

There are three major categories of pharmacologic agents:

1. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) 2. Opioid Agonists 3. Adjuvant Medications

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are the most effective pharmacologic treatment for mild pain. They have anti- inflammatory, analgesic, and antipyretic properties. Rarely is this class of medications effective against severe chronic or acute pain. These medications enhance the analgesic effects of opioids and can be safely given at the same time as opioids.

This category of medication includes the following (American Academy of Family Physicians, 2017):

 Aspirin  Celecoxib (a COX-2 inhibitor)  Fenoprofen  Ibuprofen  Indomethacin  Ketorolac

 Meclofenamate  Meloxicam  Nabumetone  Naproxen  Piroxicam  Sulindac  Tolmetin

These drugs block pain by inhibiting pain reception at the local level and are usually administered orally. These drugs are often used in the treatment of mild to moderate arthritic pain and bone pain from malignant metastasis. Each has its own group of side effects, which should be known and readily recognized by the healthcare provider who is prescribing their use and by the patient who is using them.

Most medications in these classes are available primarily in oral dose form. However, several are available in suppository form. Regardless of their form of administration, the most common side effects include the following (American Academy of Family Physicians, 2017; Lynch & Peng, 2011):

 Gastrointestinal (GI) side effects, such as heartburn, nausea, diarrhea, excess gas, constipation, dyspepsia, abdominal pain, bloody vomitus, ulcers, perforated ulcers, catastrophic GI bleeding  Cardiovascular side effects, such as increased risk of nonfatal myocardial infarction, nonfatal stroke, or vascular death (a death caused by vascular pathological conditions)  Renal side effects, including electrolyte retention, bloody urine, reduced glomerular filtration, nephrotic syndrome, and chronic renal failure  Other side effects such as extreme weakness or fatigue; dry mouth; muscle cramps; numbness; tingling; rapid weight gain; black, bloody, or tarry stools; allergic reaction (such as difficulty breathing, hives, swelling of the tongue, lips, or face)

Individuals at risk for gastrointestinal side effects of NSAIDs may be given selective COX-2 (cyclooxygenase isoenzyme) inhibitors and coadministration of a proton pump inhibitor (PPI) or the prostaglandin analog misoprostol (Lynch & Peng, 2011).

There are two types of cyclooxygenase (COX) enzymes in the body—COX-1 and COX- 2. Researchers believe that one of the main jobs of COX-1 enzymes is to protect the stomach lining. The COX-2 enzyme is not involved in protecting the stomach lining. Traditional NSAIDS (such as ibuprofen) inhibit both COX-1 and COX-2 enzymes and although pain and inflammation are reduced, the protective lining of the stomach is jeopardized. COX-2 inhibitors stop only COX-2 enzymes from working and may be less likely to irritate the stomach lining or intestines (American Academy of Family Physicians, 2017).

These side effects may be reduced by timing the administration of the medication with food consumption or the consumption of antacids. NSAIDs

 should be avoided in high doses,

 should not be given over a long period of time, and

 are contraindicated in clients with abnormal renal function or a history of ulcer disease or bleeding (American Academy of Family Physicians, 2017; Meiner, 2010).

Opioid Agonists

Opioids are the most frequently used analgesics for moderate to severe pain. Older adults are especially sensitive to this group of medications because older adults experience a higher peak blood level and a longer duration of pain relief from them than younger individuals do because physiology changes with aging. Morphine is the most commonly prescribed opioid.

The most common advice regarding the use of opioids is to “start low and go slow” and carefully monitor an individual’s response(s) until the person has received adequate pain relief.

Examples of opioids include the following (Meiner, 2010)

 Heroin  Oxymorphone  Oxycodone  Meperidine  Tramadol  Buprenorphine  Butorphanol

Meperidine is no longer preferred for the management of acute or chronic pain because of its potential for toxicity, central nervous system excitability, confusion, agitation, and seizure activity.

Transdermal fentanyl is an opioid alternative that appeals to older adults with stable pain because it results in less constipation and sedation (Meiner, 2010).

Opioid agonists are often combined with acetaminophen or aspirin in the treatment of pain and are usually prescribed as 1 to 2 tablets every 4 hours as needed. They may also be given intramuscularly, intravenously, or via transdermal patches (Perron & Schonwetter, 2001).

Common side effects related to opioid administration include the following (D’Arcy & Burns, 2014; Pasero & McCaffery, 2011; Sparks & Fanciullo, 2011):

 Abuse, misuse, addiction, diversion  Overdose  Tolerance  Constipation  Nausea or vomiting  Sedation or clouded mentation  Hormonal changes (hypogonadism, hypocortisolism)  Immune modulation  Pruritus (itching)  Myoclonus  Respiratory depression (the most dangerous side effect)  Abnormal pain sensitivity  Sphincter of Odi spasm

With the exception of constipation, most of the side effects disappear within 1 to 3 days. Antiemetics may be given as a preventive measure against nausea and vomiting. Close monitoring for sedation and respiratory depression is important, especially in the aging adult. Opioids do not tend to be effective for long-term chronic pain patients. They do not effectively decrease nerve pain and the side effects—such as impaired mentation, sleepiness, and addiction—are unpleasant. “They deaden life in lots of ways” (Cloud, 2011, p. 82). However, they are often the medications most commonly prescribed (Suddath, 2011).

Adjuvant Medications

Defined as medications without intrinsic analgesic properties, adjuvant medications include antidepressants and anticonvulsants. Adjuvant medications can greatly enhance pain management strategies by treating underlying depression or mood disorders. It is critical that clients and their families understand the important role these medications play in the relief of pain (Meiner, 2010).

Adjuvant therapies are varied and can include the following options (Hui & Bruera, 2011):

 NSAIDs  Palliative radiation  Tricyclic antidepressants  Serotonin-noradrenaline reuptake inhibitors  Lidocaine  Anticholinergic agents  Corticosteroids  Antidepressants  Anticonvulsants  Muscle relaxants  Octreotide  Anticholinergics

Adjuvant analgesics are often administered as first-line drugs in the treatment of chronic pain not resulting from malignancy (Lussier, Huskey, & Portenoy, 2004).

Cannabinoids

Cannabinoids are a group of substances related to tetrahydrocannabinol (THC) or that bind to cannabinoid receptors naturally present in the nervous and immune systems of animals. There are several types of cannabinoids (Lynch & Peng, 2011; Russo, 2008):

 Phytocannabinoids (natural or herbal cannabinoids that occur in the cannabis plant)  Endocannabinoids (naturally present in animals)  Synthetic cannabinoids (developed for therapeutic use, also called “medical marijuana”)

The Cannabis plant has a long history that spans more than 5,000 years. It has been used by ancient cultures for food, fiber, and medicinal purposes. In current times, the term “cannabis” has often been replaced by the term “marijuana” (Maida & Daeninck, 2016).

The active ingredient in cannabinoids, ∆-9-tetrahydrocannabinol (∆-9-THC), was first discovered in 1964. Today, four cannabinoid agents are available in several countries, © ALLEGRA Learning Solutions, LLC All Rights Reserved and they are used as second- or third-line agents for pain management, either as a single agent or in combination with other agents exhibiting a different mechanism of action (Lynch & Peng, 2011; Russo, 2008).

Cannabinoid therapies are varied and versatile and can include pharmaceuticals (nabilone, dronabinol, and nabiximols), dried botanical material, and edible organic oils infused with cannabis extracts (Maida & Daeninck, 2016). The guidelines for the use of cannabinoids are similar to those used for opioids. Adverse effects include euphoria (“high”), oral stinging, dizziness, drowsiness, dry mouth, fatigue, and nausea. Cannabinoids are contraindicated in patients with uncontrolled hypertension, active ischemic heart disease, paranoia, and schizophrenia (Freeman et al., 2014; Lynch & Peng, 2011; Russo, 2008).

Delivery Methods

Pain medications can be delivered in many ways including

 orally,  rectally,  transdermally,  intramuscularly,  intravenously (IV),  via continuous IV infusion,  via IV bolus administration,  via patient-control, or  intraspinally.

Spinal Cord Stimulator “Chronic pain has no solution, just a collection of imperfect options” (Suddath, 2011, p. 79). One option for the reduction of chronic pain is a spinal-cord stimulator. The small, battery-operated, pulse generator is implanted surgically into the neck or back. It sends electrical pulses to the spinal cord that interfere with the nerve impulses that cause a person to feel pain. A “trial run” is usually performed first to determine if the device will be successful. If it is successful, the patient is evaluated for a permanent placement. The batteries must be replaced every 2 to 5 years. When the stimulator is in use (often for 1 to 2 hours, three to four times a day), the individual feels a tingling sensation instead of the pain felt in the past (WebMD, 2015a). A spinal-cord stimulator is often placed for people with severe, chronic pain who have had a failed spinal surgery, severe nerve-related pain or numbness, or chronic pain syndromes (such as reflex sympathetic dystrophy). Currently, it is considered investigational for other chronic pain conditions such as multiple sclerosis, paraplegia, and intractable angina. In addition, there is still not strong proof that spinal-cord stimulation works, and treatment methods vary. However, some studies have reported more than 50% of patients who received the device after failed back surgery, peripheral neuropathy, or phantom-limb pain have experienced a reduction in or relief of their pain (WebMD, 2015a). Risks of this procedure include scar tissue around the electrode, pain moving beyond the reach of the stimulator, infection, spinal fluid leakage, headache, bladder problems, getting accustomed to the stimulation, and breakage of the device (WebMD, 2015a).

AN INTEGRATIVE APPROACH TO PAIN MANAGEMENT

For much of the last 200 years, pain treatment has not changed a great deal. The primary method of treating pain involved the use of opioids such as morphine. However, this is changing as healthcare providers realize that pain is more than just a symptom. Pain is a condition of the body, the mind, and the spirit.

To provide the most effective treatment of pain, it is essential to understand the whole person and realize that the whole person—body, mind, and spirit—experiences the pain. Complementary and alternative medicine (CAM) therapies as well as traditional medicine together provide an integrative approach to the treatment of pain. Surveys of the use of CAM therapies are showing an increasing use for those in pain (Barnes, Bloom, & Nahin, 2008).

Scientific evidence on CAM therapies for pain includes laboratory research (e.g., animal studies) and clinical trials (human studies). There are “positive findings” (evidence that a particular therapy may work and “negative findings” (evidence that a therapy does not work or that it is unsafe) (NCCIH, 2017b). An integrative health approach supports the use of conventional treatments (such as medications, surgical interventions, and support groups) as well as complementary and alternative treatments (such as acupuncture, biofeedback, or massage) for pain. In addition, the following suggestions are also important in the holistic approach to pain management (NCCIH, 2017b):

 Individuals need to seek treatment as early as possible to avoid additional problems.  Individuals cannot let past frustrations or failed treatments keep them from seeking additional options for pain management.  Keeping a pain journal helps clarify what therapies work and don’t work and clarifies times that pain occurs and potential pain triggers.

 It is important for individuals in pain to speak up and tell healthcare providers about questions they may have concerning their pain treatments, to discuss what works and doesn’t work in terms of pain treatments, and to discuss with them how their pain impacts their lives.  Taking a trusted friend or family member to an appointment can provide much- needed support and the friend or family member can take notes, if needed, to help the patient remember things that were discussed.  Individuals need to take the initiative to become as educated as possible about all types of available treatment options.

A holistic, multimodal approach is often more effective than a single therapy or strictly pharmaceutical approach to pain management. Regardless of the approach taken, the goals of pain therapy are to (Teets, Dahmer, & Scott, 2010):

1. lessen the pain, 2. improve functioning, and 3. enhance the quality of life.

The healthcare provider must conduct a complete assessment of the whole person to assure they are not overlooking (and thus, not treating) other medical conditions that might be contributing to the individual’s pain. Effectively educating the individual is a vital subsequent element of care as well. For example (Teets, Dahmer, & Scott, 2010):

 Diabetics can prevent nerve and blood vessel damage by effectively managing their blood sugar.  Individuals with arthritis can take their medications to prevent joint damage and pain from occurring.  Individuals with osteoporosis can take their prescribed medications to prevent bone loss and help prevent fractures that could result in pain and disability.  Individuals who need knee or hip replacements may need the surgery to provide pain relief or reduce the need for analgesics.

Once a conventional health care examination and assessment are complete, an integrative health (IH) assessment should be conducted. It includes the following (Teets, Dahmer, & Scott, 2010):

 An extended holistic patient history (with information about medications, nutrition, social support, work, exercise, and stress-relieving strategies)  A pain assessment (including location, intensity, sensation description, information about the onset, duration, and fluctuations, as well as what makes it better or worse, and how it is affecting sleep, mood, appetite, and activity)  Blood work, x-rays, and other pertinent tests  A spiritual history  An assessment of any use of dietary supplements  An assessment of the use of CAM practitioners (including acupuncture, chiropractic, Reiki, etc.)

 An assessment of the use of integrative health modalities/therapies the patient might be interested in exploring  Any social support (including perceived support, type of caregivers available, patient coping styles, etc.) used by the patient According to Teets, Dahmer, & Scott (2010), it may be unrealistic to aim for immediate and complete relief of chronic pain. Therefore, establishing appropriate goals of care is important and the following three goals are recommended as a starting point:

 Addressing patients’ pain in the context of the individual’s life situation (a “patient-specific context”).  Improving patients’ pain and/or improving their quality of life.  Improving patients’ risk profile by decreasing their need for multiple medications (polypharmacy), invasive interventions, and unproven therapies.

INTEGRATIVE HEALTH THERAPIES Integrative therapies for chronic pain management include the following:

 Dietary modifications  Herbs and supplements  Homeopathic medicine  Manual medicine  Acupuncture  Movement therapies  Mind-body therapies  Healing touch therapy  Magnet therapy  Stress management techniques  Self-care therapies  Mirror therapy Dietary Modifications

What we eat can have a dramatic effect on the levels of pain we feel in our body (Howard, 2011). Most research on dietary modifications focuses on anti-inflammatory diets, specifically related to rheumatoid arthritis and osteoarthritis (Goldberg & Katz, 2007; Teets, Dahmer, & Scott, 2010). These diets, especially those high in omega-3 fatty acids, positively influence the biochemical process of inflammation that is present in pain syndromes. Diets with more olive oil, less red meat, and more cold-water fish, more fruits and vegetables, and fewer dairy products (such as the Mediterranean diet) are recommended. These diets are less restrictive than other dietary regimens, are generally safe, decrease the risk of malnutrition, and are considered to be beneficial for those who want to prevent or reduce pain. If individuals choose more restrictive diets, consultation with a dietician and primary care provider, as well as supplementation with calcium, vitamin D, and vitamin B12, can be helpful (Teets, Dahmer, & Scott, 2010).

There are three major omega-3 fatty acids available in food (Teets, Dahmer, & Scott, 2010): 1. α-linolenic acid (ALA) 2. eicosapentaenoic acid (EPA) 3. docosahexaenoic acid (DHA) EPA and DHA are found in cold-water fish such as salmon, sardines, herring, halibut, and mackerel. ALA is found in flaxseeds, flaxseed oil, canola (rapeseed) oil, soybeans, soybean oil, pumpkin seeds, pumpkin seed oil, purslane, perilla seed oil, walnuts, and walnut oil (Teets, Dahmer, & Scott, 2010). Research on omega-3 fatty acid supplements shows that they can improve pain symptoms (such as joint tenderness and morning stiffness) and they can decrease the amount of medication required for patients in pain. In some cases, such as arthritic pain or nonsurgical neck or back pain, they may even be a safer alternative to NSAIDs (Maroon & Bost, 2006; Teets, Dahmer, & Scott, 2010). Omega-3 fatty acid supplements may also help reduce the pain and inflammation of rheumatoid arthritis, migraines, and Crohn’s disease (Howard, 2011). Individuals who are also taking an anticoagulant (blood thinner) should check with their healthcare provider before taking omega-3 supplements because omega-3 supplements can increase the effects of the anticoagulants. Concerns about whether it is better to ingest omega-3 fatty acids through whole foods or supplements continues. Whole foods (such as fish) may contain significant amounts of toxins such as mercury or polychlorinated biphenyls and trying to estimate the actual amount of fish oil present can be challenging. Fish oil supplements are usually free of toxins (Teets, Dahmer, & Scott, 2010). Other foods that may help to relieve pain include the following (Howard, 2011; Soeken, 2004):

 Red grapes, blueberries, and cranberries—contain resveratrol, a compound that blocks the enzymes that contribute to tissue degeneration.  Ginger—contains an enzyme that blocks the inflammatory process and may be very effective in relieving chronic joint pain.  Soy—contains isoflavones (plant hormones) that contain anti-inflammatory properties. Tofu, soy milk, soy burgers, and edamame are all excellent sources of soy.  Tumeric—inhibits a protein called NF-kB that activates the body’s inflammatory response.  Cherries, blackberries, raspberries, and strawberries—contain antioxidants called anthocyanins that reduce inflammation levels in the body.  Coffee—can contain caffeine which, in moderate doses of up to two cups of coffee a day, can reduce pain associated with exercise and raise the pain threshold.  Avocados and soybeans—contain unsaponifiables that can reduce joint pain.

Herbs and Supplements

Several culinary herbs, such as ginger (Zingiber officinale) and turmeric (Curcuma longa) have long been used in traditional medical practice to reduce inflammation. Ginger and turmeric are members of the same plant family, Zingiberaceae. Ginger has pungent ketones including gingerol. Tumeric is an underground stem and is part of curry. Studies for both ginger and turmeric have been somewhat mixed regarding beneficial effects (especially for arthritis pain) found at concentrations greater than what is found in food (Funk, Frye, Oyarzo, et al., 2006; White, 2007). However, the data are not positive enough to recommend supplements of either at this time (Teets, Dahmer, & Scott, 2010).

Adverse effects to the ingestion of ginger are uncommon but can include mild gastrointestinal effects such as heartburn, diarrhea, and irritation of the mouth. In addition, since ginger can affect fibrinolytic activity, patients taking anticoagulants should exercise caution and check with their healthcare provider before taking ginger (White, 2007). Thunder god vine (Tripterygium wilfordii) is one herbal treatment that has shown some success in the treatment of pain, reduction of the inflammation associated with pain, and in suppression of the immune system. Studies have also suggested it might have anticancer effects. Found as a perennial vine native to China, Japan, and Korea, it has been used in China for health purposes for over 400 years. It can cause many serious side effects and be poisonous if it not carefully extracted from the skinned root. Certain parts of the plant (such as the leaves, flowers, and skin of the root) are highly toxic and can cause death. Further high-quality studies on this herb are needed before its efficacy can be firmly established. There are no consistent, high-quality thunder god vine products currently manufactured in the United States (NCCIH, 2016). Devil’s claw is a hook-like herb (Harpagophytum) native to Africa. It is possibly effective for decreasing pain from arthritis as well as reducing low-back pain. It can have gastrointestinal side effects and is contraindicated for pregnant or nursing women, as well as individuals with cardiac issues, diabetes, gallstones, and peptic ulcer disease (Medline Plus, 2015). Glucosamine sulfate has been shown to stimulate the production of glycosaminoglycans (the key structural components of cartilage) and sulfur (necessary for making and repairing cartilage). Chondroitin is also a glycosaminoglycan that can be beneficial for cartilage but research findings have not been consistent in terms of its benefits. Further trials are still needed to clarify the benefits of both of these supplements. All studies agree that glucosamine sulfate and chondroitin are safe and adverse effects are generally uncommon and minor. There is a possible risk of allergy in individuals who have allergies to shellfish since glucosamine is often produced from marine exoskeletons (Soeken, 2004; Teets, Dahmer, & Scott, 2010). (NOTE: It is important to ensure that all supplements are sourced responsibly and ethically. For example, some glucosamine products are made from shark cartilage and this practice leads to the inhumane slaughter of millions of sharks annually and could potentially lead to the collapse and/or extinction of various species.) A lipid mixture of one-third avocado and two-thirds soybean unsaponifiables (ASUs) has been found to be helpful in improving symptoms and reducing the use of nonsteroidal anti-inflammatory drugs for individuals with knee and hip osteoarthritis. Adverse effects have been few. The studies have not been extensive enough to confirm the positive findings so more research is needed in this area (Teets, Dahmer, & Scott, 2010). Methylsulfonylmethane (MSM) and its precursor, dimethyl sulfoxide (DMSO), have been used for osteoarthritis but there are sparse data to support their use and at this time they are not recommended for chronic pain treatment in osteoarthritis (Bauer, 2014; Teets, Dahmer, & Scott, 2010). Side effects of MSM include stomach upset, diarrhea, and headache (Bauer, 2014).

Homeopathic Medicine This medical system believes that “like cures like.” Thus, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substance (at a higher concentration) would actually cause those symptoms. There is no scientific evidence to date that supports the use of homeopathic medicine for pain management (NCCIH, 2017b). Manual Medicine

Manual medicine therapies include chiropractic, osteopathic manipulation, massage, and craniosacral therapy and are often used as an adjunct to other modalities for pain control. An ideal person for this type of therapy is an individual without severe osteoporosis and in whom there is no serious pathology (Hart, 2010).

 Chiropractic emphasizes integration of the active (musculotendinous), passive (ligamentous), and neural (proprioceptors and nociceptors) systems of the spine for stability. According to chiropractic practitioners, without this stability, dysfunction occurs. Other body systems begin to compensate and movement impairments and pain provocation can occur (American Chiropractic Association, 2017; Teets, Dahmer, & Scott, 2010). Spinal manipulation therapy is a basic treatment tool and is often used for treatment of headaches, joint pain, neck pain, low-back pain, sciatica, osteoarthritis, spinal disk conditions, carpal tunnel syndrome, tendonitis, sprains, and strains. Research results regarding the use of chiropractic alone for pain control have been mixed (Teets, Dahmer, & Scott, 2010).

 Osteopathic manipulation views the practitioner’s role in combating diseases as that of restoring proper musculoskeletal function of the body. By removing restrictions in muscles, nerves, blood vessels, ligaments, etc. the body is able to move more freely and heal itself more effectively. This form of treatment incorporates a wide range of approaches such as spinal manipulation, connective tissue release, soft-tissue techniques, muscle energy, and cranial osteopathy. Research has shown that the use of osteopathic manipulation alone for pain control has mixed results but it has not been studied to the same degree as chiropractic therapy. As an adjunct therapy, it can be successful and it may contribute to the improvement of an individual’s psychological status, but more research is needed (Teets, Dahmer, & Scott, 2010).

 Massage therapy is one of the oldest forms of medical care; Egyptian tomb paintings show people being massaged. Massage therapy is the soft-tissue manipulation of the body by a trained therapist for therapeutic purposes. It is typically used as an adjunct therapy to prepare patients for other interventions (such as exercises) and it is helpful in relieving muscle tension and stress, increasing local blood flow, improving flexibility, increasing endorphin release, and in providing feelings of calmness. Physiological benefits of massage include tissue repair, pain modulation, relaxation, and improved mood. In research studies, massage alone has been found to be superior to relaxation, acupuncture, corsets, exercises, and self-care education for lower-back pain (Teets, Dahmer, & Scott, 2010). In one study, massage was rated as the most useful integrative therapy for low-back pain (Hart, 2010). In other studies, it has been found to be less effective than spinal manipulation therapy and the Alexander technique. In patients with chronic or recurrent low back pain, exercise and six lessons in the Alexander technique were more effective at 3 months and 1 year than massage alone (Teets, Dahmer, & Scott, 2010).

 Craniosacral therapy is a hands-on healing technique often practiced by physical therapists, massage therapists, and chiropractors. The movement of spinal fluid within and around the central nervous system is believed to create a vital body rhythm and when it is blocked, health problems develop. The therapy is believed to reestablish the normal flow of fluids and restore health (Kern, 2014).

Other methods of manual medicine, which need to be studied further to determine their effectiveness in pain management, include the following (Rolf Institute of Structural Integration, 2017; The Alexander Technique, 2014):

 The Feldenkrais Method (Functional Integration)—This is a technique that uses gentle movement and directed attention to improve movement and enhance range of motion, flexibility, coordination, and reduce pain.

 Rolfing (Structural Integration)—This technique is a form of myofascial massage guided by the body’s contours. Rolfers use their fingers, hands, elbows, and knees to place deep pressure on specific parts of the body and shift bones into proper alignment, resulting in increased flexibility, reduced discomfort, and reduced tension. Range of motion is increased and posture misalignments adjusted. Rolfing can sometimes be painful.

 Trager Approach—This form of movement consists of a series of gentle, passive movements to relieve muscular tightness without pain. It helps individuals reduce stress, improve flexibility, increase energy, and reduce constriction and rigidity.

 The Alexander Technique—This method teaches the use of the appropriate amount of effort for a particular activity, resulting in increased energy for all activities. It is not a series of treatments or exercise but, instead, strives to “re- educate” the mind and body. Adverse effects from manual medicine therapy are rare (less than 1 per million patient visits). Manual medicine therapy is a recommended therapy for chronic pain, especially for low-back pain in patients who are interested in this approach, who are intolerant of nonsteroidal anti-inflammatory drugs, or who are looking for adjuvant treatments. It is best prescribed in combination with exercise and education (Teets, Dahmer, & Scott, 2010). Acupuncture

Acupuncture is part of a system of healing within traditional Chinese medicine (TCM) and has been practiced for thousands of years. It attempts to influence the life force (energy), known as chi (pronounced chee), that flows through energy pathways (meridians) in the body. Each meridian corresponds to an organ or group of organs that control specific bodily functions. These meridians can be stimulated using specific

Modern research has confirmed the physiological effects of acupuncture, including the alteration of brain chemistry through the release of neurotransmitters and neurohormones, inducing endorphin production, increasing circulation, influencing pain- inhibitory systems, stimulating connective tissue, activating hormones and other biochemical modulators (Hart, 2010; Teets, Dahmer, & Scott, 2010). These biochemical modulators affect the central nervous system and influence the immune system and physiological processes such as blood pressure, blood flow, and body temperature regulation.

Acupuncture has been shown to be effective in improving lower-back pain and decreasing the use of analgesic medication in patients with lower-back pain. Some of the research findings and recommendations have been inconsistent (Hart, 2010; NCCIH, 2017a; Soeken, 2004). When used in conjunction with conventional orthopedic treatment (COT), however, acupuncture was much more effective than COT alone (Teets, Dahmer, & Scott, 2010). Acupuncture has also been effective in relieving cancer-related pain, particularly malignancy-related and surgery-induced pain (Chiu, Hsieh, & Tsai, 2016). Acupuncture plus pharmacotherapy is more effective than conventional drug therapy alone for cancer-related pain (Hu et al., 2016). Major adverse events with acupuncture are extremely rare and are usually associated with poorly trained and unlicensed acupuncturists (Teets, Dahmer, & Scott, 2010). Movement Therapies

Many therapies based on the systematic movement of the body have been used for pain management.

Originating in India, yoga is a form of mind-body therapy and exercise that increases flexibility, strength, and stamina as well as enhancing self-awareness, changing the context of pain, improving life styles, increasing group and social support, creating emotional stability, and improving peace of mind. There are many forms of yoga, each emphasizing different skills and paths. Yoga has been shown to positively affect the well-being of patients with rheumatoid arthritis, reduce medication use, decrease stress (through decreased serum cortisol levels and increased alpha and theta brain waves) and is an effective complementary therapy to the traditional management of arthritis and lower back pain (Hart, 2010; Teets, Dahmer, & Scott, 2010). Tai chi is a form of movement and meditation. Qi gong also combines movement, meditation, and breath regulation. They are both rooted in a philosophy of self-control. Benefits of practicing tai chi and qi gong include improved posture and alignment, restored energy, reduced stress, and a sense of calmness (Peng, 2012). Mind-Body Therapies The connection between the mind and the body in the treatment of chronic pain is especially significant. Pain affects emotions and behaviors. Research supports many therapies that can be used to influence emotions, thinking, and behavior and result in the reduction of pain and associated distress. These therapies enable the individual to self-manage many aspects of their pain, increasing the individual’s sense of empowerment and hope. Many individuals find that a mind-body approach to treatment significantly improves their quality of life. Specifically, according to Teets, Dahmer, & Scott (2010):

 The brain can undergo neurologic changes with time (called “cortical plasticity”) in correlation with sensations of chronic pain.  Repeated sensory input can create pain memories as well as help reduce these pain memories.

 Mind-body therapies can help balance stress hormone imbalances (due to pain) and create new, pain-free or more pleasant memories. There are several types of mind-body therapies discussed in this section including cognitive behavioral therapy, hypnosis, biofeedback, mindfulness meditation, relaxation, and guided imagery. Cognitive Behavioral Therapy This is one of the most commonly used behavioral treatments for chronic pain (excluding headaches and cancer pain) and it has more evidence to support its efficacy (in terms of pain, disability, and mood) than psychodynamic and behavioral therapies (Teets, Dahmer, & Scott, 2010). This therapy is based on the idea that our thoughts cause our feelings and behaviors and so we can change the way we think or act even if the situation does not change (National Association of Cognitive-Behavioral Therapists, 2016). It can be used alone or in the context of an interdisciplinary pain rehabilitation program. Hypnosis Hypnotic approaches to the treatment of chronic pain include direct suggestion of anesthesia, glove anesthesia, pain displacement, and physical dissociation. Research that compares hypnosis to no-treatment intervention shows that hypnosis produces significant decreases in pain, anxiety, and depression associated with many chronic pain problems (including low back injuries and arthritis). However, these studies did not provide a standard hypnosis technique and did not include long-term follow up. Self-hypnosis is an important additional component of the treatment of chronic pain since it gives patients much more control over their pain and provides longer-lasting benefits (Kiefer, 2016a; Teets, Dahmer, & Scott, 2010). Biofeedback

Biofeedback provides individuals with a way to control their physiologic processes through monitoring and feedback of physiologic variables (usually heart rate or skin temperature). Proponents of biofeedback maintain that autonomic nervous system (ANS) dysregulation causes pain and that biofeedback allows the ANS to be repaired. Research has shown that biofeedback is effective in the treatment of adult migraine and tension headache and results in decreased symptoms of anxiety and depression as well as decreased medication use (Kiefer, 2016b; Teets, Dahmer, & Scott, 2010). Mindfulness Meditation, Relaxation, and Guided Imagery Mindfulness meditation is a technique often used for chronic pain. It involves a detached awareness in which all thoughts enter consciousness and are then released without emotional attachment. It commonly asks the individual to focus on breathing patterns. It is the type of meditation that is most commonly researched. Studies have shown that individuals who use mindfulness meditation report moderate to significant improvement in their chronic pain (Burhenn et al., 2014; Kiefer, 2016a; Teets, Dahmer, & Scott, 2010). Relaxation therapies teach people how to relax their tense muscles, thus reducing their anxiety, altering their mental state, and reducing pain. These techniques are especially effective with headaches, back pain, or muscle spasms. Guided imagery is a conscious meditation technique that is effective for the treatment of pain, anxiety, sleeplessness, high blood pressure, spastic colon, premenstrual cramping, and depression. Healing Touch Therapy Healing touch therapies involve tactile contact or the active guiding of somatic attention on or near a painful area and include light brushing, light touch, tapping, near touch, or self-directed somatosensory attention (Teets, Dahmer, & Scott, 2010). It is based on the premise that simple touch can minimize complex central pain. For example, most people, when they hurt their hand or burn it on a stove, reflexively grasp the hand that hurts with the other hand. This is often done first—before ice or cold water is put on the hand—because this kind of self-touch reduces pain. Studies have shown that if people keep their other hand away during an injury or burn, the injured hand will hurt more than if they touch their injured hand (Cloud, 2011). There are many theories of why this type of touch seems to work. One theory is that touch is an evolutionary response because our ancestors had few other remedies for pain. Another theory is that, biologically, our body’s pain signals decrease, either in intensity or the number of signals, when touch is applied to a wound (Cloud, 2011). There are many different types of healing touch therapies, including Reiki, Therapeutic Touch, healing touch, and polarity therapy. Patients for whom healing touch therapies are used experience pain reduction, especially when highly experiences Reiki

Magnet Therapy This technique uses magnets, which produce a type of energy (“magnetic fields”) used to treat or ease symptoms of pain. Most magnets are “static” in that they do not have a charged field. Electromagnetic therapy (in which magnets have electrical currents) is effective in treating pain and should be done only under the supervision of a trained healthcare provider since there are no clinical practice guidelines for this therapy at the present time (Oiestad, 2016; Palermo, 2015). Stress Management Techniques Stress and anxiety can influence pain in many ways. When pain levels increase and the usual methods for pain relief do not work, anxiety and catastrophic thoughts can cause more distress and a vicious cycle begins. The first step in gaining control over this cycle is to create a process where thoughts are observed and understood. Stress management techniques can be employed to support this process. They include, but are certainly not limited to, the following (Robinson, Smith & Segal, 2017):

 Identify sources of stress in your life. Consider major stressors (such as changing jobs, moving, going through a divorce, etc.) as well as thoughts, feelings, and behaviors that contribute to everyday stress levels. Try keeping a stress journal to identify regular stressors and the (positive and/or negative) ways you deal with them.

 Examine your current coping skills. Evaluate which ones are unhealthy (such as drinking or eating too much, procrastination, etc.) and focus on reducing those while developing effective coping techniques such as meditation, prayer, being

out in nature, using soothing music, or using relaxing scents (such as lavender, cinnamon, ylang-ylang, or vanilla).

 Incorporate structure and predictability in daily life. this routine of activities, rest, and medication supports a controlled pace of life and reduces painful episodes.

 Incorporate exercise into every day. Activities such as tai chi, yoga, walking, or swimming help in the production of endorphins, the body’s natural pain relievers.

 Cultivate a positive outlook and positive “self-talk.” Individuals who focus on the fact that they are a whole person (mind-body-spirit) with a past and a future, special talents, and accomplishments do not allow pain to take that away from them

 Concentrate on being around positive people and places that support feeling valued and appreciated.

 Learn to live in the moment.

 Practice deep breathing.

 Make time for fun and relaxation, which can improve an individual’s morale, provide a distraction from pain, and increase one’s sense of well-being. “Fun” and/or relaxing activities increase endorphin and serotonin levels and this, in turn, often reduces sensations of pain. Fun activities can include visiting with friends and family, listening to music, reading, walking, watching a movie, engaging in creative activities, spending time in nature or with pets, or any activities that the person finds enjoyable.

Self-Care Therapies The following is a list of therapies that can be done at home as part of a self-care program for the management of chronic pain (Micozzi & Dibra, 2017; National Institute of Neurological Disorders and Stroke [NINDS], 2014; WebMD, 2015b):

 Icing—Ideal for pain related to a recent injury, inflammation due to strains, sprains, or bruises, icing can be done anywhere. Cold has a numbing effect and placing ice directly on skin can cause nerve damage so a thin towel or sheet between the skin and cold source is necessary. Icing for 20 minutes and then removing it until the skin returns to its normal color before reapplying can be done every 2 hours on a regular basis as needed.

 Use of Heat—Heat often promotes muscular relaxation and a sense of comfort. Decreasing muscular tension may reduce pain sensations. Vasodilatation occurs

locally in the area where heat is applied. This increases circulation, enhancing the removal of cellular debris, toxins, and extracellular fluid from the area of tissue injury.

 Compression—Effective for reducing swelling (cold compresses) or decreasing pain (hot compresses), compresses can be applied for pain relief depending on the particular situation. Cold compresses should not be used on individuals with circulatory disorders, certain heart conditions, or diabetes unless previously authorized by a health care professional. Wrapping too tightly must be avoided since it can cause more swelling below the affected area. Signs that the bandage is too tight include numbness, tingling, increased pain, coolness, or swelling below the bandage.

 Cold friction rubs—Effective for increasing circulation and loosening tight muscles, this technique uses a rough washcloth, terry towel, or loofa sponge to massage a particular part of the body.

 Elevation—If applicable, raising the injured or sore area on pillows above the level of the heart while applying ice helps minimize swelling can reduce pain.

 Sitz baths—Effective for reducing pain from hemorrhoids, abdominal cramping, or sciatica, these hot baths involve partially immersing the pelvic region in heated water.

 Herbal remedies—More research is needed in this area but there are several herbal remedies that are showing great promise in the relief of pain. The “ABCs” (ashwagandha, bowsellia, and curcumin) are three herbs that have been shown to reduce pain, reduce inflammation, increase mobility, and increase quality of life. Any herbal preparation should be discussed with the patient’s healthcare provider to ensure it does not interfere with other pharmacological regimens.

Mirror Therapy An intriguing integrative therapy, called mirror therapy, is used by amputees who suffer from phantom-limb pain. Phantom-limb pain was first recognized in the 1870s during the Civil War by veterans who complained of being disturbed by “sensory ghost.” Today, over 50% of amputees struggle with phantom-limb pain. This phenomenon occurs because the motor-command center in the frontal lobe of the brain does not register that the limb is gone so it continually sends a signal down the spine to the appendage, which cannot be received since the appendage does not exist. As a result, the brain keeps firing and phantom pain results (Cloud, 2011). Phantom-limb pain is a debilitating condition for which no effective treatment has been found (Ortiz-Catalan, et al., 2016).

Navy Cmdr. (Dr.) Jack Tsao, associate professor of neurology at the Uniformed Services University of the Health Sciences, in Bethesda, Md., encouraged Army Sgt. Nicholas Paupore, an outpatient at Walter Reed Army Medical Center, in Washington, D.C., to try mirror therapy to treat phantom pain in his amputated right leg. Tsao conducted the first clinical trials in mirror therapy and said he hopes to advance the study to bring relief to amputees from Iraq and Afghanistan. Photo by Donna Miles, American Forces Press Service, 1-16-08. Courtesy of the U.S. Department of Defense.

Mirror therapy, discovered in the 1990s by Vilayanur Ramachandran, a neuroscientist from the University of California, San Diego, works on the premise that the brain can be tricked into believing the limb still exists, thus easing the pain to the limb. A mirror is placed between two “hands” or two “legs” of an amputee. The whole limb is faced toward the mirror, which creates the illusion that the missing limb still exists. The results were shocking and immediate in Dr. Ramachandran’s patients (U.S. service members returning from Afghanistan and Iraq without all their limbs) who reported significantly less pain when this therapy was used. Since Dr. Ramachandran’s studies, the results have been replicated in many other locations (Chan et al., 2007; Cloud, 2011; Miles, 2008; Morgan, 2016). Mirror boxes and inflatable mirror boxes are now available commercially (Morgan, 2016). Today, virtual reality is helping individuals with phantom pain. “Augmented reality”—a form of virtual reality—has been used to significantly reducing pain in clients who have been experiencing chronic, intractable phantom pain for an average of 10 years (Ortiz- Catalan, et al., 2016; The Huffington Post, 2017). INTEGRATIVE HEALTH CONSIDERATIONS

Approximately half of all the individuals who use integrative therapies to treat their pain do not tell their primary care doctors about their use of these therapies. They are often embarrassed, fear being reprimanded by their primary care provider, or do not

© ALLEGRA Learning Solutions, LLC All Rights Reserved recognize the importance of informing their healthcare providers about the types of therapies they have utilized. This miscommunication or lack of communication can be dangerous.

Before using any therapy for the treatment of pain, consider the following issues (NCCIH, 2017b):

 Consult with a healthcare provider to discuss ALL treatment options available and describe all options currently being utilized to see how they might be included in an effective, individualized pain management plan.

 Do not use an integrative therapy as a replacement for conventional care or to postpone seeing a healthcare provider about chronic pain or any other medical problem.

 Carefully assess the safety and effectiveness of the therapy.

 Seek out credible evidence and research on the therapy.

 Talk to the integrative health practitioner performing the therapy about his or her education, additional training, licenses, certifications, and ask for information about the therapy.

 Investigate the practitioner’s expertise, background, qualifications, education, experience, and competence by checking with state or local regulatory agencies.

 Consider the quality of the service delivery including where and how the therapy is provided and if it meets regulated standards for medical safety and care. Ask to talk with other patients and consider a timeframe in which expected results should be seen.

 Think about the costs of the therapy, since many insurance policies do not cover integrative health therapies.

 Consider what can be done in terms of self-care first. Eliminate or decrease harmful lifestyle habits and begin to practice positive, supportive health habits.

 Consider the use of dietary supplements. However, it is important to note they can act in the same way as medications and may cause medical problems if used incorrectly. Their use should be discussed with the primary health care provider.

 Know the source of products that are being used. Explore the background of the company manufacturing the products, ask about standards for manufacturing, quality control practices, and standards for the active ingredients in the products. Consider the sustainability and ethics of the products you use to ensure they do not damage the environment, or contribute to the inhumane treatment of any being (human or animal) in their procurement, manufacture, or distribution.

THE FUTURE OF PAIN RESEARCH

The future of pain management is exciting. There are multiple areas of study currently underway in the area of chronic pain. Some of these include the following (Guedon et al., 2015; National Institute of Mental Health, 2016; Park, 2011):

 Gene therapy, which explores whether injecting chronic pain sufferers with genes coded for natural painkillers increases the body’s level of these analgesic chemicals. It also provides a complementary approach to pharmacotherapy.  Repetitive transcranial magnetic stimulation (rTMS) to reroute nerve connections and relieve symptoms of bipolar disorder and pain. First developed in 1985, rTMS directs magnetic energy toward the anterior cingulated cortex (the brain’s pain center).  Using functional magnetic resonance images (fMRI) to help individuals retrain their brain to control the pain pathways.  An increased role for psychiatrists in the early, effective treatment of anxiety or depression (since these patients often report higher incidences of chronic pain). SUMMARY Pain, especially chronic pain, is a significant public health issue. While conventional pharmacologic therapies can be effective in the treatment of chronic pain, integrative health therapies offer a variety of important treatment options to the patient in search of additional pain relief. Multiple approaches to the treatment of pain contribute to an improved clinical state and allow the patient and the healthcare provider to achieve a better understanding of the specific clinical issue. Mind-body approaches can support healing of the whole person and reduce pain while supporting a higher quality of life.

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