COMMENTARY
Federal Strategies for Pain and Opioids Wildly Uneven on Value of Integrative Practitioners … plus more John Weeks
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Federal Strategies for Pain and Opioids Wildly Uneven on Value of Integrative Practitioners The first months of 2016 witnessed a cascade of federal strategies, guidance, and new directions relative to mounting discomfort both with pain and the means of treatment. In a series of 3 recent articles, I analyzed the extent that nonpharmacologic complementary and integrative practices, and practitioners were viewed as part of the solution.1-3 Here is a quick breakdown. The Fact Sheet on President Barack Obama’s $1.1-billion opioid strategy is devoid of any reference to nonpharmacologic approaches.4 The final Guideline for Prescribing Opioids for Chronic Pain from the US Centers for Disease Control and Prevention (CDC) features, as step 1: “Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain.”5 The featured options, however, are limited to exercise; aquatic, aerobic, psychological, and cognitive behavioral therapy; and bio-psycho-social interventions. There is no mention of any other integrative practices or practitioners. The National Pain Strategy from the US Department of Health and Human Services (HHS) issued on March 18, 2016, 3 days after the CDC guideline, shows greater inclusion. My analysis found 15 separate mentions of complementary or integrative practices in the 55-page document. (This compares to 66 for “opioids.”) Most notably, in 4 of the 16 objectives in the strategy, complementary or integrative health practitioners were directly included as key collaborators. They were indirectly referenced as potential partners in others. One notable finding in the series of analyses is that the sponsoring federal agencies did not choose to seek advice from a very wide net of professions. With one exception, none of the advisory bodies included chiropractors, integrative medical doctors, naturopathic doctors, acupuncturists, or other professionals from these fields. The one exception was Maryland integrative academic and researcher Brian Berman, MD. He was on one of the 6 working groups for the National Pain Strategy. Berman was the sole expert in integrative pain among the 80 professionals who shaped the strategy’s objectives through working group activity.
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Integrative Medicine • Vol. 15, No. 3 • June 2016
Comment: When the Joint Commission, the major hospital accreditor, issued a “Clarification of the Pain Management Standard”6 in November of 2014, it seemed that the era of apartheid in pain treatment was over. Elevated were what they called “chiropractic therapy, acupuncture therapy, massage therapy” and other nonpharmacologic approaches. They appeared on par with pharma. Notably, that position came out of a process that began with submissions to a Joint Commission task force of research from members of the integrative health community.7 The failure of the CDC and HHS to properly convene inclusive interprofessional teams appears to have significantly limited the value of integrative elements. It is a shame, given the depth of the crisis, that policy leaders are not yet welcoming all of the tools to the tool box and professions to the table as the US body politic staggers, drug-addled, toward solutions. Chiropractic, Naturopathic, and Acupuncture Associations Step Into the Opioid Debate National organizations representing integrative practice professionals are stepping into the nation’s debate about pain and opioid strategies. In separate activities, the American Chiropractic Association (ACA), the American Association of Naturopathic Physicians (AANP), and the American Society of Acupuncturists (ASA) kicked off new initiatives to insert themselves in the emerging dialogue.8 The AANP sent a message, via media release, to the American Medical Association’s (AMA’s) president Steven Stack, MD. In a commentary, Stack had recently wondered aloud to his fellow medical doctors: “When was the last time we looked at the research on opioid alternatives?” The AANP offered itself and members as the AMA’s educator partners. The ACA promoted a “conservative” course on pain treatment through a resolution from its House of Delegates. The key positions included investigation of nonpharmacologic interventions for pain treatment, promotion of evidence-based nonpharmacologic therapies, interprofessional education, and “public health campaigns to raise awareness of drug-free treatment options for pain syndromes.”9 The American Society of Acupuncturists, in a joint statement with the Acupuncture Now Foundation, filed a 10-page document with the CDC during the public comment period on the guidance, detailing the science behind acupuncture for pain care. It concluded, “Considering the magnitude of the opioid crisis, nonopioid alternative approaches to the management of
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