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Transforming Pain Management Through the Integration of Complementary and Conventional Care 

Transforming Pain Management Through the Integration of Complementary and Conventional Care
Chapter:
Transforming Pain Management Through the Integration of Complementary and Conventional Care
Author(s):

Heather Tick

and Eric B. Schoomaker

DOI:
10.1093/med/9780190241254.003.0021
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date: 01 December 2020

In Taoism there’s a famous saying that goes, “The Tao that can be spoken is not the ultimate Tao.” Another way you could say that, although I’ve never seen it translated this way, is, “As soon as you begin to believe in something, then you can no longer see anything else.” The truth you believe in and cling to makes you unavailable to hear anything new. (Pema Chodron, Awakening Loving-Kindness1

Definition

As its hallmark, complementary integrative pain management (CIPM) offers patient-centered care that is inclusive of and collaborative with all appropriate disciplines and strategies—conventional and complementary—for the benefit of the patient. It then follows that it is multidisciplinary and team based. Patient self-actualization and self-care is essential. Its goal is health creation, and it is driven by patient priorities.

Historical Perspective

Healthcare professionals enter medicine to help people; we do not enroll in medical, dental, nursing, or other schools with the intention of harming patients. Nevertheless, there is abundant evidence that many of us cause a lot of harm. Some of this harm is due to outright blunders, but most of it is just the side effects of products and procedures we routinely prescribe or practice. The 1999 Institute of Medicine (IOM)1 report, To Err Is Human,2 and the works of Starfield,3 James,4 and most recently Mackery,5 present the alarming statistics of morbidity and mortality caused by conventional medicine. Even the most favorable analysis of these statistics is grim, and ranks medical care as the third-leading cause of death in the United States. This is deeply disturbing and should be totally unacceptable.

The prevailing management strategy in the field of pain treatment has contributed heavily to these statistics. Deaths from nonsteroidal anti-inflammatory drugs (NSAIDs) alone exceed those from HIV/AIDS.6 Unfortunately, while these data on NSAIDS have been available for nearly a decade, the treating community has failed to adjust their prescribing practices.7 The FDA has recently intensified warnings about the adverse cardiac effects of NSAIDs and amended recommendations to warn about their wholesale use, but we are aware that even when good evidence-based or recommended practices are available, there are serious deficits in their application.8

The overprescription of opioids for chronic noncancer pain has caused an even more worrisome epidemic. The use of these drugs causes tolerance, leading to escalating doses, which too often has dire consequences.9,10,11,12,13 There are now more deaths in the United States from accidental prescription opioid overdose than from highway accidents in the majority of states. Prescription opioids are responsible for more deaths than cocaine and heroin combined. This is especially alarming when we consider the recent resurgence of heroin addiction through the gateway of oxycodone and other prescription narcotics.14 Moreover, these opioids seem to have contributed very little toward actually helping our nation’s chronic pain problem. Doctors in the United States prescribe 50 times more opioids than the rest of the entire world combined, yet the prevalence of pain in the United States is increasing and there is likely to be increasing disability associated with chronic pain.15

So how did well-intentioned doctors get pain treatment so wrong? To answer this, we have to look back at the origins of modern pain medicine. In the 1950s, a prominent anesthesiologist, John Bonica, recognized that pain is a biopsychosocial disease, and together with Bill Fordyce, a psychologist, began developing theories for pain treatment. In 1961, Bonica founded the first multidisciplinary pain program at the University of Washington. He had a novel idea: Pain management required its own set of skills and its own field of study and patients were best treated by a team of professionals. Until this time, pain was treated by the specialty that claimed authority over the area that hurt—orthopedic pain was treated by orthopedists, pelvic pain by urologists and gynecologists, and so on. Bonica’s model still survives as the best way to manage complex pain.16

Dr. Bonica was an anesthesiologist, a scholarly pursuit that positioned him well to understand how drugs and procedural interventions could be used but gave the future field of pain management a bias toward anesthetic principles and practices. For this reason, most academic pain clinics are based in anesthesiology departments. This match, however, is only a partial fit. On the one hand, anesthesiologists have created enormous advancements in the safety and effectiveness of general anesthesia and analgesia during surgery. Regional anesthesia has further improved surgical outcomes and safety while providing effective pain relief as a result of major trauma or during procedures. These techniques translate well into interventional pain treatments. On the other hand, anesthesiology practice is based on a consultation model in which patients are referred by clinicians who have already done most of the diagnostics and patient assessment. Unlike the clinical and business models of other disciplines—such as internists and primary care practitioners—who come into the patient relationship with a disciplined agnosticism about what the problem is and from whence symptoms emanate, the models of anesthesiology are based on managing a problem—such as sedating a patient for surgery whose principal condition has already been sorted out by others. The very fact that the majority of pain clinic patients are referred from other entry care sites introduces a selection bias into the patients these pain management specialists are treating. They rarely see the newer pain patients, but rather are consulted for the more resistant, complex cases. This selection bias and the frequency with which pain patients are referred for consultation to specialty pain clinics and then often return to their referring clinic or primary clinical manager translates into several errors in comprehensive management of the problem or problems. There may be an inaccurate assessment of the meaning of pain within the context of the patients’ lives; the best approach to managing the pain (medications and anesthesia-based interventions); and the duration of the response to any treatment initiated in terms of subjective pain relief, its impact on patient function and comorbidity, such as sleep disturbances, mood issues (anxiety, depression, etc.), activity, and the like.

In addition, most anesthesiology-based pain programs, for practical reasons (e.g., time management, therapeutic target, financial practice models, etc.) do not focus on detailed physical examination and diagnostic reasoning, which should be considered fundamental to pain management. This skill is well established in the training programs of many other practitioners, including osteopaths, chiropractors, physical therapists, sports medicine physicians, and physical medicine and rehabilitation doctors. This may put the pain-managing anesthesiologist at a relative disadvantage. This is not a reflection on their motivations, desire to help or formidable grasp of complex science-based anesthetic modalities, but a reflection of the realities of healthcare delivery in a busy anesthesiology and pain practice. While the anesthesiology skill sets translate very well for acute pain and trauma, chronic pain demands a broader skill set and ultimately a different business model.

Bonica understood the importance of integrating nonanesthesiologist physical or manual therapy skills and disciplines into the field of pain management, and his original comprehensive functional restoration program did just that. Sadly, this integration lasted only until the workload- and business-driven culture of medicine led to reduced insurance coverage of these treatments. Most pain clinic business models remain financially viable by performing large numbers of procedures. Now, few of the comprehensive multidisciplinary programs remain, and Bonica’s novel and effective idea, his independent field of pain management, has lost much of its depth and diversity in most current practice environments.

Two Conventional Approaches to Pain

All of this has led conventional medicine to two main approaches to pain. Both groups embrace the influence of central sensitization, and promote analgesics and pain-modifying drugs such as antidepressants and anticonvulsants. One approach addresses the physical causes of pain with interventions including injections, nerve blocks, epidurals, tissue ablations, spinal cord stimulators and pain pumps. In situations of acute tissue injury and damage these procedures can save life and limb and reduce suffering. Evidence from combat-related acute pain management suggests that wounding-associated long-term secondary emotional and mental health problems such as post-traumatic stress disorder (PTSD) are also reduced by timely application of these techniques as close to the point of injury as possible.17 Once there is “chronification” of pain, interventions through blocks and other injections can also be very helpful in carefully selected patients who meet evidence-based criteria such as those put forward by the Spine Intervention Society (SIS, formerly ISIS—International Spine Intervention Society).18 All indications are, however, that the pain community as a whole does not apply careful patient selection criteria and overuses these potentially risky and costly strategies.

The second approach focuses on behavioral strategies. Chronic pain is not so much about tissue injury and nociception but is now better understood as a very patient-specific brain disorder.19 As a consequence, those who employ this second approach see psychology as the main determinant of chronic pain. Pain centers that employ this strategy deal more with the psychological, spiritual, social, and symbolic aspects of pain, and often develop strong partnerships with psychology and psychiatry departments as well as social work in those few centers that have funding. Neuroscience research, specifically in the areas of neuroplasticity and the central nervous system sensitized by past trauma, depression, anxiety, anger, and frustration, has deepened these collaborations. While these partnerships have led to useful advances in behavioral treatments for pain, they also often oversimplify the issue by failing to fully explore the contributions of predisposing, precipitating, and perpetuating physical factors.

At the end of the day, neither of these two treatment paradigms has stellar outcomes in returning people with chronic pain to functional lives. As mentioned earlier, this is because most of the tools used by our most prevalent pain models were developed for the care of acute conditions. These tools allow for a focused assessment, a rapid diagnosis, and an algorithm for treatment that is designed to act like a “silver bullet” striking at the core of the problem. If a patient is in an emergency room suffering from a heart attack, this approach can be very successful during the short window of exposure we have. It allows the patient to survive the acute episode, but the optimal strategy for long-term care of chronic heart disease must be considerably different. This is also true of acute and chronic pain conditions, between which the difference is not just timeline; it is also the lack of a clear target to hit with an isolated, less-than-comprehensive therapy. The treatment goal of rapid alleviation of signs and symptoms in the acute situation, whether it is for pain or heart disease, will be detrimental to long-term function and even survival if the root causes of the chronic condition are not ultimately addressed. In fact, even when dealing with only acute pain conditions, our limited tools can lead us astray by directing us to choose a diagnosis and commit to a long-term therapeutic approach, which sometimes reduces our list of possible pain generators. This leads us to seek panaceas—the proverbial “silver bullets” fired at the wrong targets. It launches a vicious cycle.

In some cases, our good intentions to quickly relieve suffering may get in the way of what is best for the long run by leading us to focus on the wrong things. For example, in an effort to highlight the importance of pain, our conventional medical community has dubbed pain the “fifth vital sign.” The Joint Commission added to this by requiring repeated evaluations of patients’ pain intensity using the conventional Visual Analogue Scale (VAS). This caused a single metric—a number on an 11-point scale—to become the focus of the pain visit. But as the NEJM perspective article “Pain Intensity Scores: Are We Chasing the Wrong Metric?”20 outlines, this strategy is not helping. We now treat pain scores as if they were thermometer readings, where each numerical benchmark demands specific actions. This completely ignores the lack of meaningful correlations between pain scores and the multifaceted function of patients. Chronic pain practitioners have long realized that these scores can vary in inexplicable ways, and are not useful benchmarks for treatment. Some people with 8/10 pain can function in their daily lives and some people with 3/10 pain cannot.

Perhaps the goal of chasing lower pain scores originally derived from the anesthesiology perspective that optimal pain relief is its complete ablation (i.e., the anesthetized patient), but we know now that it is unrealistic to think we can eliminate the perception of pain entirely and it may be both unnecessary and potentially injurious. Although the initial intention of this numeric assessment of pain intensity may have been good, this strategy has continually focused the chronic pain conversations on the complete elimination of perceived pain, and has led increasingly to reliance on opioid use. This has shifted us away from more useful parameters of the patient’s progress toward functional restoration. The pharmaceutical industry has been relentless in its marketing to practitioners and patients—who have both been very receptive to the message—with claims that chronic opioid use is effective, that there are advantages to long-acting opioids, that escalating doses is safe, and that pain patients cannot become addicted to opioids. None of these claims is supported by evidence.21 Ironically, the medical community’s major reliance on the use of chronic opioids has led to a second round of drug interventions for the complications of opioids, from reversing opioid-induced constipation; to treating opioid-related hormonal imbalance, mood, and sleep disturbance; to managing overdoses.

It appeals to all doctors’ good intentions to think we can help any patient quickly and definitively. We live in an impatient, quick-fix society; our patients often demand it; and we are no less susceptible to that mentality—especially when faced with the distress and disability associated with pain. As practitioners, we take pride in our ability to administer precision medicine that is tailored for a specific patient and clinical problem, and we idealize the model of a highly selective therapeutic agent. These are perhaps best represented by a well-selected antibiotic that cures a highly sensitive bacterial infection without side effects, complications, or the emergence of pathogen resistance. Newer generations of more selective immunologic-based therapies for autoimmune disorders and cancers also exhibit these idealized features. Drugs, procedures, and surgery have all seen a rise in popularity because they give us “something to do,” and they are sold with the allure of rapid and definitive results. The outcomes, however, increasingly do not match our expectations.

The conventional medical community hoped that intervention would be its savior, but now, with evidence abounding, we should know better. A review of the definition of “precision medicine” will also remind us that it is “an innovative approach to disease prevention and treatment that takes into account individual differences in people’s genes, environments, and lifestyles.”22But the practice and general public’s focus on precision medicine appears to have only focused on the chemistry of our genes and the agents that interact with genes and gene products and not the highly variable environmental and lifestyle differences among all of us.

Drugs and procedures alone, though they are used increasingly, do not improve chronic pain, and interventions and patient functionality have all too often had an inverse relationship.23,24,25 Often, proponents of drugs and intervention, including the leading pain specialists, the pharmaceutical industry, and patients themselves, invoke a trump card—our moral imperative to relieve pain. But, the truth is, outcomes of our best efforts for treatment cannot be guaranteed, whether treating pain or treating cancer and diabetes. Our moral imperative should actually be to relieve suffering (not pain), to optimize human potential and growth on all levels, to provide our best level of care, while adhering to the premier imperative: “First, do no harm.” Our goal should be to “Do good while doing no harm.”

Regardless of how our model of care ended up missing the mark for so many chronic pain patients and leading to so much collateral harm, it is clear we need a different approach. Over the past few decades, there has been a growing consensus of authorities and organizations calling for a culture change in the practice of both general and pain medicine. In 2013, the IOM published a report titled US Healthcare in International Perspective: Shorter Lives and Poorer Health, which affirms that America is doing healthcare wrong, and declares that there is no need to wait for more studies before making significant changes.26 One key topic of culture change is an emphasis on health, which the World Health Organization defines as, “a state of complete physical, social and mental well-being and not merely the absence of disease or infirmity.”27 Douglas Wood, director of strategy and policy at the Mayo Center for Innovation, described this when he wrote, “We will realize fairly quickly that we need to change the focus of the health care industry to creating health, not just producing health care.”28 To that effect, the Accountable Care Act has recognized the need to expand the contributions of nonstandard strategies, and introduced a nondiscrimination clause that directs insurers to cover a wide variety of complementary and alternative healthcare practitioners who previously had little or no insurance funding.

With specific regard to pain medicine, the IOM’s Relieving Pain in America29 and the report from the Army Surgeon General’s Task Force30 agree that we need more than minor adjustments to our current practices. This consensus is also reflected in the recommendations of the recent National Pain Strategy,31 as well as the new guidelines for opioid use from the Centers for Disease Control and Prevention (CDC). The message across the board is clear: Not only have we not reduced pain and suffering, we have added to it, and that status quo is no longer acceptable.32 The time has come for culture change.

A Fundamental Change in the Approach to Chronic Pain Management

Complementary and Integrative Health and Medicine

So what does culture change look like? As with all major shifts in the framework for our thinking and our understanding of practice, even when founded on solid scientific evidence, there will be naysayers, some of whom will be authority figures. Many doctors and other leaders of the current practices have built their careers on familiar, widely and long-held premises, and it is very difficult for them to accept new science paradigms that shift those premises and therefore their lives’ work. (An important limitation to acceptance of a new approach is that our present tools for evaluating favorable outcomes of our treatment of chronic pain, the VAS scale and workload-based models of care as described earlier, are woefully deficient.) At a recent meeting, pioneering authorities on the role of central sensitization in chronic pain stated that they thought the focus on inflammation and the microbiome was misguided. These doctors had very impressive curriculum vitaes but, then again, so too did the famous mathematician and physicist Lord Kelvin, who made the 1895 assertion, “heavier-than-air-flying machines are impossible.”

Only a few years ago, other authorities could not imagine a place in medicine for neuroplasticity. Now, neuroplasticity is taught in medical schools, but has still barely touched standard clinical practice. Perhaps the lesson here is that old habits die hard, but they do die. After all, what would our travel plans look like if they had all listened to Lord Kelvin?

Thomas Kuhn in The Structure of Scientific Revolutions33 describes the process of scientific progress, where a system of thought progresses with accumulation of scientific explanations and anomalies until a new paradigm that asks different questions causes changes to the rules of the game. This is precisely the process that faces conventional medicine at this juncture: Asking more of the same questions will not solve the present crisis in healthcare or paincare. A truly innovative paradigm is needed. As Don Berwick discussed in his keynote address to the 2015 annual meeting of the Institute of Healthcare Improvement, we need to move beyond “fixing the flat tire . . . and making the car more reliable.” We need innovation, which “abandons the car and creates an airplane.”34

Integrative medicine (IM) asks different questions. It can teach us at least two new strategies that will be essential for bringing lasting, meaningful change to our failed pain care system. The first has to do with the cornerstone of conventional medical practice—diagnosis. It is helpful to think of our current system as a game of connect the dots, where each dot is a data point. When these dots, such as imaging, blood tests, electrodiagnostics, and limited details of a physical exam or patient history, describe a shape, we give that shape a name, which is our diagnosis. Although rapid diagnosis is fully justified in acute care and life-saving situations, this process has become so ingrained in our thinking and the business model of medical practices that it is very easy to forget that a diagnosis is merely an agreed on construct that permits us to provide a coherent framework for understanding some important concerns. These concerns are the dizzying array of states of health and more often, pathology; to outline an expected clinical course, and/or to categorize our treatment options. While these categories are useful for organization, they eliminate individual characteristics by ignoring many of the dots, which are essential individual characteristics that give clues to the complex etiologies of chronic pain conditions. The diagnosis also leads to an expectation of clinical outcome, which, though it may be our best guess at the time, is often assumed to have absolute (or authoritative) predictive value. Generic diagnoses also neglect positive outliers assuming that they are irrelevant in the majority of patients, thus missing potential therapeutic options. Integrative medicine sees diagnosis as the starting point of the puzzle, not the end point, and seeks positive outliers as exemplars to be studied.

Connecting the Dots

A more significant problem with our game of collecting dots is that it focuses our attention on the dots, and away from what current science tells us is more important, the connections among the dots and the connectors. If the dots are data points, the connectors are context. And while the dots are static, the connectors are dynamic; they are constantly moving, filling in the endless blanks between dots that often appear completely unrelated today, but may be correlated tomorrow. The connections are the critical intersections among the genome, environment, and lifestyle used to describe precision medicine. Some connections are intellectual constructs—relationships among variables. Others identify more physical, biochemical, and other material linkages. It was by focusing on these connectors that medical science revealed that multiple sclerosis (MS) is primarily an immune disorder and not a neurological one; that part of the microbiome, Helicobacter pylori, causes recurrences of duodenal ulcers; and that both physical or psychological stressors can affect the same biochemical, proinflammatory cascade in the body. By weaving between and among and through the dots, these connectors demonstrate far more complex and unique situations than our traditional diagnoses can express, and therefore a more complete, albeit more complicated, picture of a patient’s health. We can probably all think of a patient whose data points told us a different story from their context. Examples include the patient whose spinal magnetic resonance imaging (MRI) images looked terrible but who had very good function, or the patient with a hemipelvis who was taught to walk even though they were missing key parts. Integrative medicine does exactly what its name suggests; it focuses on the integration of parts. In other words, IM is all about the connectors.

It should not be surprising that many of the body’s most notable connectors have been misunderstood or overlooked in the past; their roles are more difficult to define than those of most individual body parts. In a study of medical error, Graber et al35 found that failure to adequately synthesize data was the most significant cognitive contributor to adverse outcomes. It is easier to focus on the dots. The microbiome, as mentioned earlier, is a mass of microorganisms located mainly in the gut that affects digestion, the immune system, and mood. Although it was 100 years ago that the Nobel laureate Élie Metchnikoff drew much attention to the microbiome by declaring it a major determinant of health, over 90% of all papers about the microbiome were written in just the past decade. It is likely that the medical community largely ignored this connector for so long because of the amorphousness of “a mass of microorganisms.” This was coupled with a bias that microorganisms are largely pathogens, not symbiotic agents of health and well-being. Nevertheless, we now know just how important the microbiome is to a patient’s health, and how easily it can be affected by both endogenous and environmental factors, including drugs, chemicals, and the foods and foodlike substances of the modern diet.36,37,38,39,40,41

Another notable connector, fascia, has long been misconstrued as an inert structure with no dynamic function. It was thought to simply define and delineate boundaries, but studies now suggest it is more about connection than delineation, and acts as a crucial means of force transmission.42,43,44 Fascial fibers surround each myocyte and create a fine, three-dimensional network of crisscrossing strands that connect many structures in the body and are constantly being remodeled. Fascial pathways connect the right and left sides of the body, upper and lower limbs, and all internal organs, including the brain, which helps to explain many previously unexplained symptoms.

The process of inflammation also serves as a connector that has generally been considered a troublemaker and the root cause of most chronic disease. It is a bodywide reaction that affects every tissue type, and its chemical mediators circulate throughout the body, linking immune responses to blood clotting; to renal, pulmonary, and cardiac function; and to a range of other organ functions and dysfunctions. It explains why certain patterns of disease are often found in clusters in individual patients. But there is also a lesser-addressed, positive side to inflammation; it is the first step in healing. The tissue response to inflammation draws in platelets, white blood cells, and fibroblasts, all of which fight infection and heal damaged tissues. Unfortunately, our pharmaceutical anti-inflammatory drugs reduce both the negative and positive effects of inflammation and are therefore often more harmful than helpful.45,46,47

Neuroplasticity, the process by which experiences change the nervous system, was not recognized as a connector for a long time. Experiences that cause neuroplastic changes include injuries, activities, thoughts, and attitude changes, all of which can alter the connections within the nervous system, affecting the cellular function of many sites and even change their structure. The process of central sensitization, which is the most commonly discussed part of neuroplasticity in chronic pain settings, was initially regarded as a one-way black hole of altered nervous system function that exacerbated an individual’s sensitivity to normal stimuli, caused pain, and reduced function. The latest science, however, demonstrates the possibility of ongoing changes that can reverse this process. There is a tremendous capacity for the positive influences of neuroplasticity to enhance function of the psychosomatic system.48,49,50,51,52,53 Influences as disparate as exercise and consuming turmeric can enhance the formation of new brain cells throughout life, and learning any type of new skill increases new synapse formation in the brain giving our cognitive functions more resiliency.

Epigenetics is a connector between the effects of the environment, lifestyle choices, and current experience and the more static genome. Epigenetics is the process of methylation, acetylation, and other processes, that influences DNA transcription and translation, thereby altering gene expression rather than DNA sequencing. Epigenetics has transformed our thinking about determinants of health. Altered gene expression is proving to have great impact on health outcomes.54,55

Salutogenesis

Integrative medicine can also inform and guide our management of chronic pain with a second revision to our fundamental notions of human health. Integrative medicine has a focus on health, as opposed to a disease focus. From medical and professional school education onward, we are oriented to states of disordered physiologic and behavioral function; we are generally taught to spend most of our efforts reacting to pathological findings. In other words, we focus on the factors that cause disease far more than we do those that create and maintain health. This despite the obvious fact that the body spends almost continuous activity healing and sustaining health. Research studies on healthy lifestyles tell us that the opposite approach yields far better results.56,57,58 Aaron Antonovsky coined the term “salutogenesis” to describe this inherent capacity to heal, sending us searching for ways to create positive conditions in which healing can take place, also known as optimal healing environments (OHE). These OHEs can be summed up as environments “in which the social, psychological, spiritual, physical, and behavioral components of health care are oriented toward support and stimulation of healing and the achievement of wholeness.59,60 “In looking at human health and illness in this way, the practice of medicine becomes both more daunting and more invigorating, as all of a patient’s interconnected health and illness factors become possible points of intervention in the process of salutogenesis.

As was already discussed, IM is all about the connections and connectors, which include more than just the anatomical and physiological ones listed above. An OHE is a wider-angle lens through which we can consider not just the microconnectors, like the microbiome, but also the equally important macroconnectors, such as the relationship of the patient to the practitioner, to the system of medicine, and even to the community and the environment as a whole. While conventional medicine pays little attention to these macroconnectors, emerging science tells us that they are crucial, and that it is not by accident that ancient healers and folk healers and shamans in many cultures today enlist the help of their entire village in their medical practice.

Foundational Elements to Improving Patient Outcomes

We now know that lifestyle choices have a more profound impact on population health outcomes than genetics and all our medical management interventions combined. While genetics accounts for 20%–30% of our health outcomes, epigenetics—our environment and what we eat, drink, think, feel, and do—accounts for 70%–80%. Lifestyle choices affect which of our genes are turned on or off,60 which influences overall health outcomes by changing host susceptibility to disease and the ability to heal. The European Prospective Investigation into Cancer and Nutrition–Potsdam Study (EPIC) evaluated the effects of four lifestyle factors on health—never smoking, a BMI under 30, physical activity for at least 3.5 hours a week, and eating a healthy diet that includes vegetables, fruit, whole grain bread, and low meat consumption. The study followed 23,000 people for 7.8 years and demonstrated that those with all four factors at baseline had a 78% lower overall risk of developing a chronic disease. More specifically, these individuals reduced their risk of diabetes by 93%, myocardial infarction by 81%, strokes by 50%, and cancer by 36%. All of these diseases and, in fact, all of the chronic diseases that were tracked in EPIC can impact pain. These findings are particularly significant when compared to the results of interventions; there are no drugs or procedures that come anywhere close to producing these benefits. Recognizing the impact of lifestyle choices on health is the key to culture change within our healthcare system, and is an effective platform for changing the conversation around chronic pain.

Nutrition

Most chronic disease is fostered by an acidic61,62 and proinflammatory environment in the body. Nutrition plays a crucial role in this; with every meal eaten, food choices either increase or decrease inflammation in the body. All too often, healthy choices are difficult for people to make, either because healthy foods are not available (or affordable), or because education about optimal nutrition is lacking. In the United States, politics and business have worked together to make processed foods cheaper than fresh, whole, unprocessed foods. Subsidies to huge corporations support the growing of grains, which are used to create relatively cheap, mass-produced meat (consuming much of these grains) and processed foods, while vegetables remain expensive and even inaccessible in some parts of the country. The US Department of Agriculture (USDA), which issues food recommendations for the nation, has a stated mission that focuses more on economic innovation than health.63 In fact, the USDA has issued food recommendations that support the use of heavily processed foods containing high levels of sugar and refined carbohydrates devoid of nutritional value, against the advice of its own nutritional advisers.64,65 This strategy has led us to an epidemic of chronic illness and obesity. It is estimated that one in three Americans will become diabetic in their lifetime—a figure that increases to one in two for Hispanics, African Americans, and Native Americans. Record numbers of preteens are obese, diabetic, or showing signs of coronary artery disease. In an outrageously profitable business model, cheaply priced fast foods create ample customers for hospitals, insurance companies, and pharmaceutical companies. And pharmaceutical companies win in two ways; drugs are used without prescription in animal food production as well as with prescription to treat the human health consequences of the Standard American Diet (SAD). This diet is dominated by processed foods—almost 80% of which contain added sugar66—and is high in calories, unhealthy fats, refined carbohydrates and sugar, salt, and chemicals such as pesticides, stabilizers, antibiotics, and preservatives. Fiber, vitamins, minerals, and antioxidants are missing from the SAD (sad, indeed), which serves up nutritional deficiencies despite excess calories.67 It is no coincidence that many chronic pain patients eat very unhealthy diets; with the increasing prevalence of obesity, cardiovascular disease, and diabetes come the complications of other chronic diseases and pain syndromes.

Studies evaluating the influence of diet on inflammatory markers show that diets high in fiber, healthy oils, vegetables, and fruit but low in sugars, starchy carbohydrates, and unhealthy oils can reduce inflammation and disease.68,69,70,71 Thus, by increasing or decreasing inflammation, food choices influence the brain and body function much as the contents of a fuel tank influence how well a car runs, or the quality of soil influences how well a plant grows.72,73,74

Paradoxically, many doctors who hesitate to prescribe supplements and restricted diets for fear of harming patients do not hesitate to prescribe drugs for pain or inflammation, or other drugs to lower cholesterol, blood pressure, or blood sugar. The CDC statistics are very clear on the relative risks of food and supplements versus drugs—the greater potential for harm is with drugs.75,76,77,78 But while these prescribing trends are paradoxical, they are also perfectly understandable; we are all more comfortable with what we know. The 4-year curriculum at most conventional medical schools allocates thousands of hours to learning about pharmacologic agents, and only a few hours (if any) to nutrition. Often, graduates not only are ill-prepared to advise patients on the subject of nutrition but also do not even know how to eat well themselves. We know that doctors who smoke are less likely to stress smoking cessation to their patients,79 and we can assume that this same relationship applies to doctors who have other unhealthy habits or who lack healthy ones, such as eating a healthy diet. After all, it is not a logical stretch to assume that those healthy living elements we feel are important in our own lives, such as diet, exercise, and sleep, are also considered important in the lives of our patients.

What distinguishes an unhealthy diet from a healthy one? All diets consist of macronutrients—protein, fat, simple carbohydrates, and complex carbohydrates—which provide the calories in our food, and micronutrients—vitamins, minerals, enzymes, and antioxidants. An unhealthy diet is an unbalanced one, and, in America, that tends to mean an overconsumption of macronutrients and an insufficient intake of micronutrients. On average, an American consumes 150 pounds of sugar and 150 pounds of refined flour every year, and over one-third of their calories comes from junk food.80 Americans tend to eat too much animal protein,81 but neglect vegetable protein and have a high intake of processed grains,82 resulting in the overconsumption of unhealthy fats, but a very low intake of unprocessed fruits, vegetables, beans, legumes, nuts, seeds, whole grains, herbs, and spices, which is why we lack fiber and micronutrients.

Walter Willett—professor of epidemiology and nutrition and chairman of the Department of Nutrition at Harvard T. H. Chan School of Public Health, and one of the most frequently cited medical authors who publishes extensively on diet and its effects on well-being and longevity—has outlined the evidence for the health-promoting effects of a proper diet, and provides an alternative food pyramid to My Plate—the latest recommendation from the USDA. The base of Willett’s pyramid is composed of whole grains and plant oils, followed at the next tier by unlimited vegetables and 2–3 fruits per day. Nuts and legumes are next, followed by fish, poultry, and eggs, and then dairy or calcium supplementation. At the very top of the pyramid are red meats, butter, sweets, and “white foods,” meaning white bread, pasta, potatoes, and rice.83 These should be used sparingly.

Moderate use of coffee, tea, wine, and dark chocolate has been shown to be beneficial because of their antioxidant content. When consuming these products, however, it is important to be aware of their source and quality, as all of them tend to be produced with heavy usage of pesticides, and are sometimes chemically altered. The Environmental Working Group84 is a nonprofit organization that compiles lists of sources and contaminants and makes them available to the public.

Processed grains and sweetened foods are called high–glycemic index (GI) foods because they cause a rapid rise in blood sugar (BS) followed by an insulin spike. Low-GI foods, on the other hand, produce only small fluctuations in BS and insulin. Large fluctuations in BS and insulin begin the path to insulin resistance and diabetes, accompanied by an increase in inflammation, which, as already mentioned, is a factor in the development of most known chronic degenerative diseases.85,86,87 These include medical and psychiatric disorders such as, metabolic syndrome, diabetes, cardiovascular disease, cancer, autoimmune disorders, schizophrenia, and depression, all of which have adverse effects on health and life expectancy and can complicate the experience of pain. High-GI foods are also addictive, which leads to overeating.88 Furthermore, processed foods, grains, and animal products promote low tissue pH, which reduces the activity of essential physiological enzyme reactions and mitochondrial energy production in the body and itself is a cause of pain.89,90 Green vegetables, lentils, and most fruits raise tissue pH to more optimal levels.

In addition, processed and high-GI foods adversely affect the microbiome.91 Artificial sweeteners, such as aspartame and sucralose, and many common occurring chemicals, pesticides, and food additives also harm this crucial connector discussed earlier. While the microbiome only weighs about 6 lbs, its cells outnumber our human cells 10 to 1 and it has incredibly diversity—it contains 100 times more DNA than our human DNA.92 The balance of this genetic diversity greatly impacts human health and disease; it affects the absorption of nutrients, causes or prevents excessive gut permeability, affects the function of the immune system, may be responsible for some forms of abdominal pain, and can stimulate unhealthy fermentation within the gut. For example, we have known since the 1990s that gut bacterial imbalances can cause abnormal colonic fermentation, which can present itself as irritable bowel syndrome.93 Martin Blaser in Missing Microbes, outlines the health consequences of the loss of diversity in the microbiome due to modern diet, drugs, and chemicals.

Besides an unhealthy diet, other factors that can disrupt the microbiome include many non-life-saving drugs such as NSAIDs, proton pump inhibitors (PPIs), antibiotics, steroids, and hormones. These drugs can also cause significant morbidity, mortality, and micronutrient depletion,94,95,96,97,98,99 and these changes can impact pain.

While it is important to eat a healthy diet, we are also not just what we eat; we are what we ingest, digest, and absorb. In the nutritional process, the digestive system is supposed to play the role of gatekeeper; as digestion takes place, the gut wall is supposed to act as a pathway for needed nutritional molecules to be absorbed into the body, and as a barrier to toxic ones and pathogens. Recent research shows, however, that inflamed intestinal mucosa can lead to increased gut permeability, which allows the entry of bacteria, toxics, and partially digested nutrients. Eighty percent of the immune system lies adjacent to the gut, which enables rapid reactions to immunogenic substances crossing the mucosal barrier. In the case of increased permeability, absorption of pathogens and immunogenic molecules leads to increased bodywide inflammation, and may enable the development of autoimmune disorders in susceptible individuals.100,101 Increased permeability was once called leaky gut by nontraditional practitioners, before it was finally validated and accepted by mainstream science and medicine. Of course, increased permeability is just one of many factors that affect proper digestion. Another essential component is sufficient stomach acid, which triggers gastric emptying, stimulates the secretion of digestive enzymes, and enables absorption of many minerals, vitamin B12, and protein.102

Most Americans tend not to absorb enough nutrients, because of both a patent lack of nutrition and digestive problems. And while a whole-foods diet, properly digested, will always be the best basis for nutritional sufficiency, supplements such as multivitamins can be regarded as an insurance policy to provide a baseline level of nutrients. This can guard against fluctuations in health and food intake that may increase need or decrease the supply of nutrients.103

As with food, the health risks associated with nutritional supplements are minimal. Although the safety profiles of nutritional supplements must continue to be monitored and evaluated, the National Poison Data System, which tracks deaths from drugs and supplements, reported no deaths due to vitamins A, B, C, D, E, or any other vitamin, and no deaths attributable to amino acid or other dietary supplements in their 2010 report.104 There have, however, been recent reports of adverse effects from supplements tainted with pharmaceuticals. The National Center for Complementary and Integrative Health (NCCIH) provides a website that lists drug-tainted supplements.105,106 These supplements are mostly those used for body building, weight loss, and sexual performance,107 and are not embraced by IM practitioners. This issue of contamination, while important for public safety, is one of quality control and reflects the adverse effects of the contaminating drugs, not the underlying supplements.108,109 This problem of quality control is also apparent in situations where the ingredients of supplement bottles are found to differ from their labels.110

Although nutritional supplements should generally be considered safe, as with all things, there are specific micronutrients or supplements that can adversely interact with certain states of health and disease.

There are many vitamins, minerals, antioxidants and botanicals that can benefit pain patients. Those reviewed here are some of the most studied and readily available, and have demonstrated effectiveness in improving inflammation, pain, and healing.111,112,113 Micronutrients also have an impact on the comorbidity of depression and anxiety, which have been shown to exacerbate pain. A series of clinical trials repeated in many countries has linked micronutrient and fish oil supplements to reduced levels of violence in prisoners and of delinquency in children. These trials that link nutritional status to psychological status are of particular interest when we consider that psychological states have already been linked to adverse outcomes in pain.114,115

Vitamin D

The population of the northern hemisphere is generally vitamin D deficient,116,117 and those deficits are even more profound in chronic pain populations on both sides of the equator.118,119,120 Vitamin D supplements have been shown to improve pain as well as improve muscle strength in men and women.121,122 Vitamin D functions more as a hormone than as a vitamin and is necessary for every system and cell type that has been studied so far. Deficiencies are associated with inflammation and susceptibility to illness, and sufficient levels are necessary for a healthy immune system. Deficiencies are more common in the elderly, the obese, and those who have more skin pigmentation. Testing of serum 25OH vitamin D is the best way to gauge the optimal amount needed, because gastrointestinal absorption, states of inflammation, and other factors cause some patients to require high levels of supplementation to achieve optimal serum levels. It is generally regarded as safe for people to take 2,000 IU per day orally, and the No Adverse Effect Level (NOAL), an international standard, has been set at 4,000 IU daily.123

Omega-3 Oils

The omega-3 oils (n-3) and omega-6 (n-6) polyunsaturated fatty acids (PUFAs) are essential nutrients that we must get from our diet. North Americans generally ingest too much n-6 and insufficient n-3. Linoleic acid is the predominant n-6 that promotes inflammation, and the main source is from vegetable oils. The n-3s are docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), found in fish, organic free-range eggs, and even grass-fed beef, and alpha-linolenic acid (ALA), from plants such as flax. The n-3s promote anti-inflammatory physiology and are being studied for treatment of a wide variety of conditions (headache, rheumatoid arthritis, discogenic pain, and others) with positive outcomes ranging from reduced pain, reduced needs for analgesic medications, and improved quality of life indicators.124,125,126,127,128 The doses used are in the range of 3,000–4,000 mg of combined EPA and DHA, which can usually be found in 6,000–8,000 mg of fish oil.

B Vitamins

The B vitamins are coenzymes for reactions essential for fundamental cellular function—particularly in adenosine triphosphate (ATP) production and detoxification. Increasingly, research is looking at the connection between inefficient mitochondrial function and damage to mitochondrial DNA as underlying defects in chronic pain states, including myalgias, neuropathic pain, fibromyalgia, and chronic fatigue.129,130,131,132,133,134 Many of the B vitamins act as methyl donors in the processes of mitochondrial protein and nucleic acid synthesis and methionine and glutathione metabolism. Deficiencies of the Bs negatively affect many systems: neurologic, hematologic, cardiovascular, bone metabolism, and many aspects of muscle function.

B12

Deficiency of this B vitamin has been most studied in connection with homocysteine damage to the endothelium in the development of hyperalgesia. The mitochondrial electron transport chain is ATP dependent and is being studied in relation to neuropathic pain—specifically the effect of reactive oxygen species (ROS) on chronic regional pain syndrome (CRPS). There may be common mechanisms in mitochondrial myopathies and fibromyalgia where mitochondria are adversely affected by substrate and cofactor deficiencies as well as inhibition by drugs and industrial chemicals.135,136

B12 deficiencies have long been known to cause neurological dysfunction and chronic pain. Absorption from food sources depends on adequate stomach acid and intrinsic factor and declines with age. B12 tissue levels are likely more significant than serum levels and may be better correlated with methylmalonic acid (MMA) and homocysteine levels. In both active treatment arms of a double blind, placebo-controlled, crossover trial, Mauro137 found that daily B12 injections in pain patients with normal B12 levels resulted in reduced pain scores and analgesic use. A British study138 found that preservation of brain value correlated positively with B12 levels within the normal range in 61- to 87-year-olds without cognitive impairment. The normal values for B12 in Japan have a much higher range than in the United States, and there are controversies regarding the best way to assess B12 sufficiency.139,140 There is growing recognition that fatigue, depression, and nonspecific lack of wellness may accompany insufficient levels of B12.

A month-long trial of 1,000 mcg sublingually, taken daily, may produce improved symptoms of pain, insomnia, and fatigue. This route of administration avoids injections while still bypassing any impairment in gastrointestinal absorption. If not effective, a trial of self-administered daily injections may be tried.

Vitamin C

A powerful antioxidant and cofactor, vitamin C is essential for tissue repair and adaptation to stress. It is needed for the production of hormones, neurotransmitters, bone, and collagen, which are all important to physical and psychological well-being and healing.141 Vitamin C increases iron absorption, and higher serum vitamin C levels are associated with lower blood lead levels. Unlike most animals, we humans cannot produce vitamin C, which makes it an essential nutrient that must be consumed. Vitamin C needs vary from day to day based on stress levels, physical activity, injury, and sickness. A 70-kg goat makes 13 g of vitamin C per day and more when stressed.142 A moderate dose is 2,000 mg per day. Current research is reevaluating our vitamin C needs for optimal health.

Magnesium

Magnesium is one of the most common nutritional deficiencies in the American diet.143 It is an intracellular mineral, like calcium, and levels are likewise tightly regulated. Our bones and muscles act as reservoirs of magnesium, and these reservoirs can be depleted without changing serum test levels, which may appear to be normal. Magnesium plays a role in over 300 essential metabolic reactions.144,145, It is needed for synthesis of protein, DNA, RNA, glutathione, carbohydrates, and lipids. It also plays a role in cell signaling, optimal bone density, collagen production, and regulation of serum glucose.146 It controls the rate of nerve firing and is an excellent muscle relaxant. People with fibromyalgia, nocturnal leg cramps, high blood pressure, and cardiac arrhythmias are often magnesium deficient. Magnesium should be the first line choice for bodywide inflammation,147 muscle cramps, spasms, myofascial tightness, and trigger points. Magnesium can reduce migraine frequency148 and the cramping and pain of irritable bowel syndrome,149 can improve sleep,150 and is now being studied for its role in neuropathic pain.151

Some forms of magnesium are better absorbed by the body, and are therefore better distributed to tissues, than others. These forms include chloride, glycinate, citrate, and ascorbate. Other forms, such as oxide, hydroxide, or sulfate, are not well absorbed by the gut and are more likely to cause diarrhea. Patients should take as much of a good-quality magnesium as can be tolerated with the goal of producing 1–2 easy-to-pass bowel movements per day. The daily dose may vary from a few hundred milligrams to much higher doses for those with severe deficiencies. The result of overdose is diarrhea, which stops when the dose is lowered.

Glutathione Precursors

There is growing literature on the role of mitochondrial dysfunction in the development of chronic neuropathic and inflammatory pain. A review paper by Sui highlights “five major mitochondrial functions” that impact chronic pain (the mitochondrial energy generating system, ROS generation, mitochondrial permeability transition pore, apoptotic pathways, and intracellular calcium mobilization).152,153 Most of us rolled our eyes when we had to memorize the Krebs cycle, but its relevance to daily practice is becoming ever more apparent. It turns out, mitochondria are another crucial connector, which maybe should not come as a surprise; cellular energy production and detoxification are obviously cornerstones of any healthy body.

In our society, sensational problems often receive far more notice than common ones. For example, while severe mitochondrial disorders capture our attention because they are life threatening, we do not pay much mind to lesser forms of mitochondrial dysfunction caused by damage to mitochondrial DNA because they are far more common. Similarly, extreme lead poisoning in Flint, Michigan, makes the headlines, but reports on ASTDR.gov about the association between lead levels within the normal range and delayed development, learning disorders, and behavioral disorders goes unheeded. Likewise, it is well-recognized that nutritional supplementation helps the severe neurological and psychiatric disorders caused by untreated vitamin B12 deficiency, while the studies that show reduced levels of violence in prisoners given nutritional supplementation are not being acted on.

These three examples are not random. Problems of mitochondrial dysfunction, exposures to even low levels of toxics, and nutritional deficiencies all affect the efficiency of the Krebs cycle and the inability of mitochondrial DNA to recover from oxidative damage. This damage is caused by high-energy particles called free radicals that interact with the components of cells at many of sites, including DNA, lipids, cell membranes, and proteins like intracellular enzymes. Free radicals act by stealing electrons. Free radicals are caused by external agents such as smoking, exposure to toxics, and radiation including cosmic rays or internal processes of normal metabolism. And while each of our cells suffers millions of “hits” every day by free radicals, mitochondria are particularly susceptible to oxidative damage because they generate free radicals during normal function and also suffer from exogenous free radical attack. When this damage accumulates, it becomes oxidative stress, causes inflammation, and plays a role in degenerative disease. For this reason, mitochondria create an enormous need for antioxidants, which are electron donors that repair the damage caused by free radicals. Antioxidants will help to prevent mitochondrial dysfunction, which is suspected of playing a role in neuropathic pain as well as fatigue in multisystem disorders.154 Unfortunately, some of the very agents we look to for solutions—drugs—also interfere with mitochondrial function through the disruption of glutathione pathways. The most effective solution is therefore a nutritional one.

Glutathione is a key survival antioxidant that recycles other antioxidants and is essential for mitochondrial and liver enzyme detoxification function.155 Methylation is a metabolic process that is necessary for mitochondrial energy production, detoxification, and free radical damage repair. These nutritionally dependent processes are important players in some pain syndromes. High levels of homocysteine from deficient methylation and deficiencies of glutathione can create macrovascular damage, and thus cause coronary heart disease156 Microvascular damage is now being recognized from the same causes and may be a mechanism causing neuropathy and hyperalgesia.157,158,159,160 Single nucleotide polymorphisms of the MTHFR gene that can cause reduced levels of methylation are being studied in conditions that will impact pain medicine. There are animal studies demonstrating the benefits of antioxidants such as vitamins C and E and coenzyme Q10 (CoQ10 or ubiquinone) on chronic pain. Milk thistle is an antioxidant and free radical scavenger that raises the intracellular glutathione levels studied in many different disease models, including thallassemia,161 diabetes,162 drug-induced liver injury,163 and more. N-acetylcysteine (NAC) stimulates phase II liver enzymes, disarms free radicals, and repairs damaged DNA. It also helps the liver produce glutathione.164 In addition, NAC protects the body against a wide variety of toxics, including heavy metals, which it binds into complexes so they can be excreted from the body.

Oxidative phosphorylation (OXPHOS) reactions are critical reactions on the inner mitochondrial membrane: OXPHOS defects reduce mitochondrial ATP production, and “can theoretically give rise to any symptom, in any organ or tissue, at any age, with any mode of inheritance.”165 Medication-induced mitochondrial damage and disease has been associated with many common medications including NSAIDS, Aspirin, acetaminophen, antidepressants, local anesthetics, anxiolytics, antipsychotics, statins, oral hypoglycemic agents, and anticonvulsants.166,167 There is a growing body of research looking at subtle and acquired OXPHOS disorders secondary to environmental toxics and many drug exposures. These last two facts might explain why clinical medicine is lagging behind the science. Though we may be used to complex patient scenarios, it is a leap to get our heads around the idea that “any symptom, any system” can be caused or affected by mitochondrial dysfunction. If we then take away most of the drugs we commonly use to help people because they may be contributing to the problem, common practice protocols become impossible. While this would be a wearisome treatment model to embrace, it is at least worth our awareness and consideration in the area of difficult-to-understand pain syndromes. At the bare minimum, we should explore exposures to heavy metals and common toxics and avoid non-life-saving polypharmacy. Supporting mitochondrial function with antioxidants has been shown to be effective in improving ATP production. Positive effects have been shown with CoQ10, ascorbic acid, vitamin E, riboflavin, thiamine, niacin, vitamin K (phylloquinone and menadione), and carnitine.168 CoQ10 should be considered essential for anyone on a statin drug, since HMGcoA reductase enzyme reduces CoQ10 production. CoQ10 is essential for mitochondrial function, and deficiency may result in muscle (including heart muscle) and nerve dysfunction.

Turmeric and Ginger

Turmeric and ginger come from the botanically related plants curcuma longa, and Zingiber169,170,171 respectively. They have anti-inflammatory properties, which are at least in part due to the disruption the cyclooxygenase-2 (COX2) pathway at many points leading to a more nuanced influence on inflammation. Ginger and the main active ingredient of turmeric (curcumin)172,173 have similar effects as pharmaceutical NSAIDs but without the harmful side effects. Other actions, besides COX2 inhibition, are being studied. It has been found that turmeric root plays a role in the preservation of cognitive function, which may be partly due to neurogenesis174 through the promotion of stem cell differentiation. This seems to be a property of the whole root—either fresh or dried as a spice—and not the extracts of curcuminoids. Turmeric also inhibits phase I liver enzymes and activates phase II.

Systematic reviews of both turmeric (root and extracts) and ginger have significant beneficial effects on pain and function in osteoarthritis.175 Clinical trials have shown curcumin reduces perioperative pain176,177 and reduces the need for other analgesics. A 2009 review of hundreds of studies on turmeric and its use for a variety of complaints concluded, “turmeric appears to outperform many pharmaceuticals in its effects against several chronic debilitating diseases, and does so with virtually no serious adverse side effects.”178

Cinnamon

This spice is being shown to inhibit inflammatory cytokines and has been studied in rheumatoid arthritis and dysmenorrhea. It also reduces blood sugar levels and insulin resistance through its “insulin-like” mechanism that allows glucose to bypass the insulin receptor on myocytes. Chromium and magnesium also optimize blood sugar levels and can impact pain states by reducing inflammation and general health complications that accompany insulin resistance.178

Quercetin

Quercetin is a plant-derived flavonoid that has antioxidant and analgesic effects.179 Glucosamine and chondroitin have been shown to be beneficial for cartilage healing and preservation in osteoarthritis.180

Given the importance of the microbiome for overall heath as well as the multiple challenges that modern living presents for the microbiome, it is prudent to recommend fermented foods to replenish the microflora, and probiotics (beneficial bacteria) and prebiotics (nutrients that nourish the microbiota) when there are known exposures to adverse circumstances.

There are many different types of elimination diets that can be useful for patients to try. A systematic use of an elimination diet can help sort out reactions people have to foods, food additives, or even pesticides and contaminants. Gluten intolerance has been called an underrecognized trigger for headaches and a cause for uncontrollable blood sugars in some diabetics. One percent of the population has Celiac disease, and 10% have genetically determined gluten intolerance. (REF) There seems to be increasing levels of gluten intolerance continent-wide, and the reasons for this are unclear. In North America, there is very heavy use of pesticides on most nonorganic grains, and many pain patients feel better with a trial of restriction of gluten or all grains.

Nightshades are a family of plants that have long been recognized as a source of joint pain and stiffness in some animals and people. A 6-week trial off nightshades—tomatoes, potatoes, all peppers except white and black peppercorns, and eggplant—may improve some patients’ pain.

Nutrition research seldom looks like drug research. Drugs have dramatic therapeutic effects as well as the potential for dramatic side effects. Nutrients work more subtly, slowly, and physiologically than drugs because they are naturally occurring substances that our bodies are programmed to recognize, utilize, and excrete appropriately. Of course, there are rare metabolic disorders, allergies, and intolerances to foods that can cause adverse reactions in a small group of people.

Nutrients work synergistically with each other, and while drug-style randomized-controlled trials of isolated nutrients over a short period of time have provided some information, the major impact diet has on health occurs when overall nutritional status improves.

People rarely get drug deficiencies but they regularly get nutritional deficiencies. The 2004 JAMA article concludes, “Poor diet and physical inactivity account for four hundred thousand deaths, or 16.6 percent of total deaths, per year in the United States.”181 Our heavily processed, high-GI diet causes diabetes, depression, cardiovascular disease, and obesity, all of which are risk factors for adverse outcomes in the cases of painful conditions and the procedures used to treat them.

Emerging Areas of Nutritional Links to Pain Syndromes

New research is pointing to immune dysfunction, beyond the obvious autoimmune disorders, as a player in clinical pain syndromes. This way of thinking connects distinct tissue types, distant anatomical sites, and varied physiological functions, all potentially affected by immune activation, and accounts for some of the complex and confusing syndromes we see. For example, there is a relationship of mast cell activation with interstitial cystitis and chronic pancreatitis. Experimental pain models have demonstrated that activated macrophages can cause the release of inflammatory mediators tumor necrosis factor alpha (TNF alpha), interleukin 1-beta (IL-1beta), nerve growth factor (NGF), nitric oxide (NO), and prostanoids, all of which can cause clinically relevant pain pathology.182 There is mounting evidence that industrial food additives are adversely affecting intestinal tight junctions, leading to increased gut permeability. This is a suspected mechanism that can lead to the observed increase prevalence of autoimmune disorders,183 many of which are pain associated. Recently discovered lymphatic connections to the brain are revealing a more extensive role for the immune system in both the function and dysfunction of the brain.184 The blood-brain barrier is increasingly seen as less of a protective barrier.

Xenobiotics are foreign chemical substances, many of which are neurotoxic or endocrine disruptors. Many of them find their way into our food and water supplies. Neutrophils may be playing a role in nerve injury leading to hyperalgesia,185 secondary to both injury and xenobiotic attack. These circulating leukocytes respond to injury by migrating to the site of inflammation and moving into the nervous system.186 This raises interesting possibilities for understanding the development of sensitized pain states and the possibility that xenobiotic substances are possible initiators of these reactions. This may help explain why we seem to have an epidemic of ill health and intractable pain states. There have been over 75,000 new chemicals introduced into the environment between 1960 and 2000, and most of them have not been subjected to safety studies. Heavy metals, especially mercury, lead, cadmium, and arsenic, are frequently found in modern humans, and can interfere with many metabolic processes.187 Some groups have very high risk of exposure to multiple chemicals. These groups include farm workers, residents living close to chemical plants, chemical industry workers, and the military. The aging water infrastructure in most large cities contains lead, which is a known neurotoxin. Unfortunately, we have not been systematically looking for xenobiotic exposure in our chronic pain patients, and so we give them diagnoses that may be very incomplete, and therefore miss effective solutions. This makes Malcolm Gladwell’s observation especially salient: “We have, as human beings, a storytelling problem. We’re a bit too quick to come up with explanations for things we don’t really have an explanation for.”188

The Connection Between Mind and Body

Both popular Western notions of health and disease and the conventional medical system that attempts to prevent, diagnose, and manage disease suffers from a nearly 300-year-old “mind-body dualism” that has been attributed to Rene Descartes. The brain and all body systems use a single instantaneous communication network mediated by the same molecules.189 There is a multidirectional communication system between the cerebral cortex, limbic system, and hypothalamic-pituitary-adrenal axis that is both influenced by and sends output to the periphery, which includes all organs, endocrine glands, the immune system, and the central and peripheral nervous systems (somatic, sympathetic, and parasympathetic). There are modulations from mind to brain to body and back again. Recent scientific advances are disrupting the mind and body schism of Descartes, and indicate that connections between these two spheres are unavoidable in the effective management of chronic conditions, especially chronic pain syndromes. This field of medicine has been called mind-body medicine (MBM) or psychoneuroendocrine immunology. This is closely related to the field of biofield science, which is “an emerging field of study that aims to provide a scientific foundation for understanding the complex homeodynamic regulation of living systems.”190 Biofields are “endogenously generated fields, which may play a significant role in information transfer processes that contribute to an individual’s state of mental, emotional, physical, and spiritual wellbeing.” Biofield treatment of pain could be “bottom-up” processes, such as reductions in cellular inflammation or nociceptive signaling and/or “top-down” processes such as cortical nociceptive control mechanisms.

The concept of biofields places us in the context of the world of physics.191 Physicists tell us that we, like all observable matter, consist of more empty space than solid matter, with numerous electromagnetic connections among the “dots” that make up the subatomic and atomic particles. Biofields may lie within these connections or at a larger more macroscopic dimension. Looking at chronic pain through the lens of a united mind-body/biofield makes it obvious that there can be unintended and very poorly understood repercussions to any intervention we make when we chase isolated features of a pain syndrome, such as nociception, mood, or sleep disturbances. For example when we raise serotonin or norepinephrine, what are the repercussions for the dopaminergic reward system? A comprehensive, integrative approach could set its goal on endpoints that enhance health rather than merely ameliorate symptoms.

Mind-body medicine practices can interrupt the cycle of stress and thereby improve a patient’s sense of well-being and resilience to all manner of stressors.192 Stress is proinflammatory. The stress response (fight or flight) shuts down many nonessential bodily functions such as digestion, immune response, and reproductive functions; it shrinks the hypothalamus and has a net proinflammatory effect on many tissues.193 This explains many of the symptoms accompanying pain syndromes and indicates possible treatment strategies. Mind-body medicine techniques, through their effects on mind-brain-body physiology, are cost-effective interventions to mitigate the effects of chronic stress (Box 21.1). Kabat-Zinn and others showed that a mindfulness-based meditation practice by a treatment group decreased pain-related drug use, improved activity levels, and increased self-esteem relative to the control group. At the 15-month follow-up in Kabat-Zinn’s study, the improvements continued and there was a high level of compliance with ongoing meditation practice.194,195,196,197,198,199,200 Other studies, including a trial at the Ford Motor Plant for back pain have found mind-body interventions useful as adjunctive therapy to ameliorate pain, to enhance treatment response, and to reduce drug use and costly, risky interventions.201

The 2009 Nobel Prize in Medicine recognized the research on “caps” on strands of chromosome or telomeres and the enzyme that maintains them, telomerase. Shortened telomeres are associated with reduced longevity, and chronic stress was shown to cause accelerated telomere shortening and therefore premature aging.202 Research has also shown that meditation and a healthy lifestyle can preserve the length of telomeres.203

Many mind-body therapies are disdainfully referred to as placebo effects. This comes from the long history of placebos being used as representatives of no active treatment, to which drug activity was being compared. But the issue is far more complex than this. When Kaptchuk used a placebo intervention as the active arm of an irritable bowel syndrome (IBS) study—in which patients were told they were receiving an inactive pill that sometimes improves symptoms—he found that the placebo caused a statistically significant improvement.204 Placebo and the placebo effects are an emerging area of study that represents the ill-understood effects of the treatment and the context of treatment. Being in pain is stressful, and interacting with the pain care system has been called one big nocebo experience due to the stressful aspects of interacting with the healthcare system. An essential element of the OHE is the reduction of stress that has the potential for improving the suffering associated with chronic pain.

Central Sensitization and Movement

Non-neuronal cells in the central nervous system (CNS), such as microglia, have been shown to both contribute to and resolve damage in the CNS. Microglia have a surveillance function in their resting state,205 but when activated they can cause damage to peripheral nerves or the CNS, leading to persisting pain states and heightened responses to stimuli. This state is called sensitization and has been demonstrated both peripherally and in the CNS. Hyperalgesia (the experience of severe pain in response to an uncomfortable stimulus) and allodynia (severe pain response to a nonpainful stimulus)206 have long been recognized as sensitization states associated with sympathetic nervous system dysfunction. Microglial activation has been shown to be a factor in their development. In addition there are now many experimental models and studies showing that there is a connection between peripheral and central sensitization; psychological stress can both lead to a centrally mediated pain sensitization and enhance the peripheral effects centrally. Somatic pain and sensitized peripheral nerves and nociceptors can cause central sensitization, which further heightens the experience of pain. It is a two-way street. Clinically, it is unclear how to distinguish peripheral from central sensitization in all instances, and they can be co-occurrent.207,208 The work of Cannon209 and Rosenblueth The Supersensitivity of Denervated Structures: A Law of Denervation210 dates back to the 1940s, but has been overlooked in the current conversations about sensitization. This work adds another dimension to this complex process.

Once the centralized process is established, there can be output from the CNS to diverse areas of the body, which helps to explain the symptom complexes of multiple seemingly disconnected systems affected by pain including muscle pain, bladder irritability, and intestinal cramps. The dysfunctions may be interconnected through central sensitization. Pharmacologic solutions for these symptom complexes have only been partially effective.

To further expand on the bidirectional nature of central pain sensitization, current clinical focus on central sensitization looks mostly at how the brain affects the body by sensitizing it to pain. But there is the other half of the equation—the influence of the body on the function of the brain. A succession of small physical injuries can accumulate and reach a tipping point resulting in pain, impairment, or disability. In these cases the onset of symptoms seems sudden and out of proportion to the stimulus. This is because once a threshold is met, the reactions are no longer linear: this can be explained by the reorganized, sensitized peripheral and central nervous system. By the time the person is symptomatic their myofascial system and nervous system have made significant accommodations and the body in pain causes changes in C-fiber excitability (called wind-up), alters function of the dorsal horn neurons, and augments nociceptive reflexes.211 The somatosensory cortex also becomes reorganized, resulting in altered sensory perception and movement initiation and effectively creating a movement disorder.212,213,214 Other reactions include cocontractions of opposing muscle groups and the loss of fine motor coordination. Movement can then become awkward, inefficient, and increasingly painful. This disorder of movement can explain muscle fatigue and exercise intolerance in chronic pain patients. How this process evolves in any one individual patient is difficult to explore because usually the injuries are in the distant past or are too subtle to be detected by usual examination and imaging techniques. There are therapists who address movement and can be very valuable as part of pain clinic treatment teams. Physical therapists Shirley Sahrmann in the United States and O’Sullivan in Australia have a robust interest in movement-based contributors to pain and using movement retraining as a treatment strategy.215,216

Many people in chronic pain develop fear of movement. This kinesiophobia is exacerbated by nonindividualized, formulaic practices in physical therapy that often allow for visits that are too few and too short to address the issues of maladaptive movement patterns of chronic pain patients. The difficulty of arriving at clear explanations for many pain syndromes leaves patients and practitioners uncertain and confused about whether a painful activity is harmful (pain that indicates ongoing tissue damage) or merely hurtful (painful movement that is not causing increased damage). Movement and exercise have many well-known benefits by stimulating positive changes in mood, anxiety, cardiovascular health, breathing patterns, tissue oxygenation and detoxification through sweat, improved parasympathetic and sympathetic tone, the release of endorphins and other communication molecules, increased strength, and better sleep. Exercising any part of the body affects the entire body, and movement improves patients’ resilience and promotes increased neuron production and synapse formation in the brain.217,218,219 The American Physical Therapy Association recently recognized movement as a system within the body. “The human movement system comprises the anatomic structures and physiologic functions that interact to move the body or its component parts.”220

Without proper guidance, patients who are chronically injured often accomplish movements by using unsustainable movement patterns for the task. Understanding optimal muscle recruitment patterns and the compensatory patterns that develop secondary to pain and injury may explain exercise intolerance. Therapists trained in the details of optimal muscle recruitment patterns and compensatory adaptations can teach patients to recruit and train patterns that can be sustainable over the long term, but much of standard physical therapy education does not cover this material. Ancient exercises such as yoga, tai chi, and qi gong can be useful at retraining movement patterns. The movement therapies such as Alexander, Feldenkreis, and Bartinieff techniques are also helpful. Chiropractors, osteopaths, and kinesiologists also bring experts to this area of functional restoration.

In summary, because pain augmentation and abnormal patterns of movement develop due to contributions from the central nervous system and the peripheral nervous system, and are influenced by physical and psychological factors, potential treatments can come from any of these areas, thus reinforcing the interconnectedness of the system of systems that we are. This leads us back to the Bonica model of team-based care, which draws strength from the diversity of its interprofessional team.

Everybody in Healthcare Is a Pain Practitioner—Or Should Be

Most medical visits are initiated because of a pain complaint. The most common reason that people seek out complementary and integrative medicine (CIM) and integrative practitioners also involves a pain complaint.221 Yet pain education in medical schools has for decades been acknowledged to be inadequate.222,223,224,225 This has led to a gap in services that in turn has led patients to seek out other types of practitioners. Another gap filled by CIM is the attention paid to whole patient226—body, mind, and spirit rather than just the narrow biological diagnosis, and the opportunity to address factors such as nutritional status, poorly managed stress, social supports, coping skills, ergonomics, and exercise.

We are faced with growing numbers of disabled people with pain, and the situation is financially unsustainable. The situation is perpetuated by a workforce of professionals of different disciplines that is not organized into collaborative, cooperative, interprofessional teams whose efforts are based on whatever is best for the patient. The adversarial insurance system exacerbates this problem by tying compensation for health claims and disability to particular structural abnormalities and diagnoses while denying coverage for many disciplines. Many of these disciplines are expert at coaching patients in self-care strategies, thus empowereing them to take control of their health. An internal locus of control or self-efficacy is a positive prognostic indicator for improvement.227,228 These barriers discourage diversity in the treatment options available for complex pain problems. Shifting to team-based, interprofessional care can improve our ability to provide more diverse responses to address the complexity.

Symptom control in CIM is a positive byproduct of improving health and lifestyle changes. Self-care by the patient becomes the cornerstone, and primary care and specialty/subspecialty care practitioners all play critical roles. The complementary integrative healthcare (CIH)/CIM approaches should be “front-loaded” as soon as possible in the acute and early chronic pain phases to promote self-care and self-actualization and to avoid potential injurious medications and procedures. Patients are often pleasantly surprised to shift their focus and see themselves as a person pursuing health rather than fleeing symptoms. This shift makes primary care practices the ideal setting in which to address most pain care. The use of nonconventional CIH/CIM practices are common worldwide and even in the United States and Canada there is an increasing demand for IM care despite very poor or even no insurance reimbursement. The World Health Organization estimates that 80% of the population of the southern hemisphere receives at least part of their primary care from nonallopathic practitioners. In some first world countries the use of this type of care already exceeds 75%.229

Perhaps we should regard our body as we do our dental care or our cars: we need to be assessed regularly for degenerative changes and to have preventative maintenance. This shift in focus would make it easier to think of health-promoting, movement-based solutions to physical pain rather than palliative drugs and procedures. This would encourage the use of surgical repair only when there is imminent irreversible loss of function because it is only rarely effective to alleviate pain.

Case Study in CIH/CIM Approach to Chronic Pain

What do these two IM habits look like in practice? Let us look at the case of Jennifer, a 46-year-old woman with a fibromyalgia (FM) diagnosis. Six years ago, she was injured in Afghanistan while in the military. Her right arm was broken and required a plate with pins, screws, and skin grafting to treat the initial injury. After the accident, she went to physical therapy, which helped her regain her arm function, but her pain eventually got worse, despite continued sessions. She subsequently developed extreme fatigue and muscle pain in her neck, shoulders, and back. The physical therapy then seemed to be making her worse. Finally, she stopped therapy and was given her FM diagnosis, but she does not know how that diagnosis helps her. Before the accident, she had been an active runner, but now, with each passing year, she has less capacity for exercise. These days, she gets headaches and muscle cramps, does not sleep well, is tired all the time, craves sugar and starchy foods, and gets particularly sleepy after eating. She sometimes gets dizzy and sometimes has diarrhea. She also has patches of dry skin with red bumps.

She works as an accountant, but is struggling to keep her job, as her manager is no longer happy with her performance. She used to work in a toxic environment exposed to persistent organic pollutants. She also has a past history of abuse. She has stopped seeing her friends because they do not understand how ill she feels, and she hates feeling like a complainer. This has led her to feel lonely and isolated.

Her x-rays show that she has reduced lordosis in the cervical and lumbar spine. Her blood work is normal, and her gastrointestinal assessment reveals normal stool cultures and no parasites. Her physical exam reveals a normal neurological exam with no weakness, and normal reflexes. The rash has been called a “nonspecific dermatitis,” and the muscle cramps come and go but are worse at night and are being called “restless leg syndrome.” One of her doctors recommended a cholecystectomy even though the work-up for gall bladder disorders only showed a mildly shrunken gall bladder. She has had epidural steroid injections, facet blocks, and it has been noted that her symptoms are too widespread to respond to a spinal cord simulator. She was tried on a dozen different drugs, including several antidepressants of different classes, gabapentinoids, proton pump inhibitors (PPIs), muscle relaxants, and opioids, which made her feel drugged. She eventually stopped all of them because they did not help, and she did not like feeling sedated.

Jennifer feels frustrated with her situation and with her diagnosis, and perhaps rightfully so. The label of FM gives us very little information on how a person got to such a state, or how to help them. It does not give the clarity that some other diagnoses do, such as pneumococcal pneumonia, which provides a clear target for treatment, some insight into prognosis, and an expected trajectory for recovery. With a clear target, we can act like sharpshooters and, most of the time, the drug or procedure we pick will work. But FM is not a clear target, and adding a series of other vague diagnoses, such as central sensitization, postural orthostatic tachycardia syndrome (POTS), irritable bowel, eczema or rosacea, does not make it any more of one. A drug, or two, or 10 may improve some of the symptoms listed above, but are unlikely to move this patient any closer toward health and functional restoration.

Using the two principle approaches discussed above, an IM physician would start by broadening the discussion with Jennifer past her diagnosis, and then by applying the least harmful interventions and the ones most closely aligned to Jennifer’s own physiology, which will support the capacity of her body to heal itself. Box 21.2 shows Jennifer’s immediate to-do list, which would be tailored in 1–2 months to fit her updated status.

Notably, most of these interventions require Jennifer’s active engagement. There is no magic bullet here that will “fix” the problem. Patients have been trained to seek out medical advice looking for answers, and we in medicine have been trained to feel inadequate when we do not have those answers. In most sciences, such as engineering and physics, the scientist defines the problem before they are expected to come up with solutions. But sometimes the best we as medical practitioners can do is to explain to our patients that healing is a path and that, while we cannot walk it for them, we will coach, guide, encourage, and accompany them on their journey.

The management of Jennifer’s FM diagnosis after her severe physical injury is only one example of an approach that works for many other types of chronic pain associated with other conditions, including post-spinal-surgery pain, headaches, chronic musculoskeletal pain from accidents, degenerative arthritis, pelvic pain, inflammatory bowel disorders, and the recent epidemic of pancreatitis, to name just a few. Even when invasive interventions and surgeries are necessary, approaching the patient to improve health and healing is advisable and will lead to better outcomes. Just as when building a house we need proper materials, when helping someone heal we need an understanding of the patient’s physiology, resilience, and context for healing —nutritional status, physical conditioning, psychological and social stressors, the effectiveness of their circulation, and their ability to effectively excrete waste materials and environmental toxics including drugs. This is especially true with invasive procedures that are a major challenge to the body which is a homeostatic, dynamic system of systems. Efforts to improve health habits before and after procedures may improve outcomes.

This IM approach and the focus on salutogenesis require time and effort, and, in an ideal setting, integrative pain medicine is practiced with interprofessional teams that use all appropriate healthcare strategies and disciplines. In the case of chronic pain, there are many individual patient characteristics that help clarify the predisposing, precipitating, and perpetuating factors that contribute to their condition, and a broad treatment team will make it easier to address as many of those characteristics as possible. Of course, perspectives will inevitably vary among team members; the diversity of observations and inputs, in the end, is for the patient’s benefit. In addition, as integrative strategies such as nutrition- and movement-based therapies often require the patient’s active engagement, the patient should be considered a member of the care team—the centerpiece of the team’s focus and strategy.

Pain has been and always will be a major challenge to humanity. It has been with us since the beginning of the human experience. But its persistence and our inability to interrupt its impact on ongoing suffering and disability is because our most prevalent models of care are using limited tools. We have narrowed the aperture of our approach to pain management—especially chronic pain management—to a very narrow avenue. The current system of pain management prioritizes treatments in a therapeutic order230—high-impact, high-risk interventions with high rates of associated morbidity and mortality—that is counterproductive. Correcting this requires that we prioritize salutogenesis and health creation. By reserving risky drugs and interventions as last resorts, we can deliver more personalized care, achieve more sustainable results, and reduce the harm caused by the medical system.

Additionally, patients need to be active partners in a new system that takes their priorities and values into account. This system will change the implied contract with our patients, and will not allow business models to dictate the pathways of care. A resetting of priorities is in order: “If not now, when? If not you, who?”231

System Transformation

For acute and chronic pain to be effectively managed in a fashion that “Does Good While Not Doing Harm” there is a need for a fundamental transformation in how we conceptualize pain, how we organize our approaches to the patients’ needs, the role of the patient and principal supports, the range of provider skills needed, and our business model for sustaining a new system of prevention, mitigation, and management. These changes require systemwide cultural revisions, not simply transactional modifications at the point of care delivered. This transformation to integrative pain care that brings evidence-based complementary and conventional modalities together requires a quantum leap. We must undergo a reversal of the current conceptual, clinical, and business models where nontraditional services are tried almost as an afterthought when all else has failed. Using complementary practices as a “last-ditch effort” in well-established chronic pain has seriously biased the perceived utility of these approaches.

The current system reinforces illness behavior, since every transaction is predicated on a diagnosis of some dysfunction (i.e., the ticket into the appointment is a complaint). The brief appointment times do not allow for a full exploration of the state of the person who is reduced to being a patient, who is attended by the medical expert—“the sage on the stage”—at the convenience of the system. The system is good at creating and maintaining people as “customers” in a commercial transaction, overlooking our fiduciary responsibility to serve the patient’s needs without attention to material reward or betterment of the practitioner or care system. The result is that everyone suffers—the patient, the provider, the family, the community—large and small. The standard for the industry right now prioritizes administrative needs and neglects both the patients and the healthcare providers. In addition to the earlier mentioned health hazards generated by the system of medical care, nearly 50% of doctors are experiencing burnout and they kill themselves three times more often than other professionals.232 Transformation requires that we shift away from many of the assumptions, paradigms, and systems of practice that have led us into our current problems.

Early System Adopters: The Veterans Health Administration and Military Health System

There have been isolated examples of early adopters of integrative pain care delivered by interprofessional teams since the 1990s. But military medicine and veterans’ healthcare in the United States—centering increasingly on interagency coordination through the work of groups such as the Defense and Veterans Center for Integrative Pain Management (DVCIPM)—are changing their culture with the large-scale adoption of these strategies. The recommendations of the Military Health System (MHS) Review and Veterans Health Administration (VHA) Pain Management Directive are in line with other federal pain management initiatives including the National Pain Strategy, the IOM Report “Pain in America,” and the CDC guidelines that recommend the inclusion of nontraditional health services with interprofessional teams. As in civilian medicine, chronic pain and its management have been recognized as problematic by the Department of Defense and Veterans Affairs health services. The military and VHA have been more proactive than civilian medicine in addressing the problems arising from use of opioids—lack of effectiveness with chronic use, the morbidity and mortality with high doses, and the risk of dependence, addiction, and diversion—responding with a mandate for cultural transformation within their system of care. The use in the MHS and VHA of such therapies as chiropractic, yoga, massage, acupuncture, and lifestyle coaching are recognized as vital in these communities for the treatment of pain due to the evidence basis for their effectiveness, their robust patient acceptance, and broad safety margin.

The military has adopted a tiered pain management strategy pioneered early in the VHA (“Stepped Care Model”), where initial pain management implementation strategies are coordinated within the primary care setting or Patient Centered Medical Home (PCMH).233,234 For more complex cases there is the opportunity for comanagement in conjunction with a regional Interdisciplinary Pain Management Center (IPMC) using consultation, collaboration, and educational opportunities. While emphasis is placed on pain care being managed in the primary care setting, the system fully allows for referrals to the regional IPMC and functional restoration programs. Such a model is very dependent on adequate education of primary care providers, enhanced through the use of the Extension for Community Healthcare Outcomes (ECHO) program developed by the University of New Mexico.235,236 Finally, there is the inclusion of nonconventional disciplines providing evidence-based approaches such as yoga, massage, music therapy, tai-chi, chiropractic, and acupuncture, in the compensation equations. These nonconventional providers who have long been told they are “bad for business” in the setting of fee for service, drug- and procedure-based medicine, are “good for business” in an accountable care setting.237

Collaborative Pilot Programs in Integrative Comprehensive Pain Management

Recent attempts to explore the lessons gleaned from leading civilian integrative care programs as well as from the military and veterans care systems have employed all of the foundational elements described in the previous sections: a reconceptualization of what causes and perpetuates pain; the essential role of the patient in self-care and self-actualization; a team-based, multidisciplinary approach integrating the best of CIH/CIM with conventional pain care to tailor to the patients’ unique needs; and a sustainable business model for providing care. One such effort, under the auspices of the Samueli Institute, used an Institute for Healthcare Improvement “breakthrough collaborative” approach.238 The process began with the establishment of clear goals and patient-focused outcomes, benchmarked the initial state of achieving these goals, and then iteratively applied a learning model to launch initiatives and measure improvements—or stalled efforts—to improve desired outcomes. These and other transformational experiences reinforce the individual, site-specific nature of a successful comprehensive pain management approach and the need for organization-wide buy-in for the plan to succeed.

Conclusion

Our collective maturation and more granular understanding of the complex nature of acute and chronic pain are providing great promise for a transformational breakthrough in how pain can be prevented, mitigated, and ultimately managed. Ironically, the advent of more advanced neuroimaging, including studies that combine structure with function; of genomic and proteomic biomarker studies; and of systems analysis of the many connections that maintain the health of an individual and restore that health in the event of injury or illness has reinforced the need for a full integration of emerging technologies with proven conventional modalities and millennia-old complementary practices. But what is needed is a major overhaul in our cognitive and organizational approaches to pain care. As Albert Einstein famously observed, “We cannot solve our problems with the same thinking we used when we created them.”239

What is apparent is that there are essential elements of this transformational effort. Beginning with the aforementioned reformulation of our notions of pain generation and the transition from acute to chronic pain, we have outlined these foundational aspects of the least elements of what must occur. Engagement of the patient as the best advocate for self-healing and preservation of health is fundamental and essential. Embracing sound healthy habits, including exercise, a nutritional diet, sleep, and assisted self-inquiry and/or observation of the individuated links between pain and its associated suffering and disability are needed. Everyone within the support system of each patient and everyone involved in providing care to the patient becomes a pain practitioner on a patient-centered, multidisciplinary team of complementary and conventional providers. All must be cognizant of the close connection between mind and body and how their effort to intervene—or disciplined withholding of intervention—contributes to relieving the suffering and comorbidity associated with pain.

The experience in military and veterans’ healthcare is influencing the movement toward transformation within civilian care as well. Integral to this process is a shift in how to think of the determinants of pain in the context of overall health, how to assess or measure the effectiveness of treatments, evaluate cost-benefit ratios, and openly incorporate team-based interventions including nonconventional ones as an integral part of care rather than as an afterthought. This allows for the synergistic effects of multiple approaches and individualized care. The importance of coordinated messaging, which focuses on function and enables patient empowerment, is key to the transformation of care. Health creation is the new goal, and it cannot be achieved if we only focus on diagnoses.

We stand at a unique place in the history of the understanding, management, and relief of suffering and disability associated with one of the cardinal experiences in human life—pain. It is as important as the first synthesis of morphine, the discovery of the anesthetic properties of ether, the mapping of the somatosensory cortex and John Bonica’s and Bill Fordyce’s introduction of comprehensive team-based pain care. In concert with these significant milestones, the intellectual and practical requirements will necessitate a transformation in how we think, work, reward, and measure our progress. “The proper management of pain remains, after all, the most important obligation, the main objective, and the crowning achievement of every physician”. . . in fact, of us all.240

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