Dr. Richard Nahas: How I Use CAM Therapies to Treat Chronic Pain

I am a pain physician leading a team of providers, and together we provide integrative pain management. Our approach is based on the principles and practices of integrative medicine, an emerging but not yet fully-accredited medical specialty.

Integrative medicine is defined as healthcare that incorporates so-called Complementary and Alternative Medicine (CAM) therapies with guideline-based diagnosis and treatment.

I really enjoy my workdays, which are mostly spent combining clinical decision making with hands-on treatment. Having spent some time as a general practice integrative physician, I enjoyed seeing a wide range of disorders. It was really fun to see improvements in such a wide range of chronic diseases, and like most docs who have learned integrative medicine, I feel that it has much to offer our profession and the patients we serve.

I decided to focus my practice on one disease category so that our patient outcomes could be used to generate more meaningful research data. I chose to treat chronic pain because it makes me feel good to see suffering patients leave my office with a smile on their faces, and because most pain physicians agree that CAM has a role to play in their patients’ care.

My referral-based OHIP pain clinic is an interventional one. I perform peripheral nerve blockade and trigger point injections on most of my patients. I use procaine, which has a half-life of minutes but which somehow manages to deliver days of pain relief. I also ensure that appropriate imaging and lab tests have been done, which for me often includes screening for vitamin deficiencies, endocrine dysfunction and systemic inflammation.

While I am keen to provide recommendations about Natural Health Products (NHPs) and specific therapies, my OHIP pain clinic patients are like yours - they have no money to spend on such luxuries. When they can afford them, I supervise therapeutic trials of many NHPs. This includes fish oil, magnesium, melatonin, vitamin B12, 5-HTP, coenzyme Q10, probiotics, curcumin and many others. I usually expect to see clear improvements within one month at a therapeutic dose. We try one NHP at a time, and can usually establish a useful regimen within a year.

I prescribe drugs the same way, but usually with shorter trials. I often write prescriptions for a one-week course of nabilone, pregabalin and amitriptyline. I tell patients how to titrate their dosing, and within a month they are able to tell me which one they prefer. I do the same thing with NSAIDs, allowing patients to compare them for themselves. When I prescribe opioids, I do the same with equianalgesic doses of three different drugs.

Many of my patients have no money at all, so for them I focus on what I can do with my hands. I combine palpation, myofascial release, active and passive stretching and contraction with tapping, eye movements and acupuncture needles. I have learned a number of different techniques at conferences, and have developed a few tools of my own. The first half of my appointment time is spent doing injections and the second half is spent doing this. We end with homework, which some of my patients don’t do but which I think is helpful overall.

I also do a lot of counselling, education and hands-on teaching. I show patients how to breathe, how to stretch. I try to orient them to good posture, both sitting and standing. We talk about pacing and avoiding flares, about goal-setting and the importance of a daily routine. I want them getting fresh air and sunlight, spending time with people, and doing things they enjoy. We talk about negative thoughts and emotions, and how to prevent them from worsening pain.

Some physicians have argued that interventional pain management only provides short-term relief, but I feel strongly that this relief is a critical element of any successful pain management program. It gives patients what I call a window of opportunity during which they can do more stretching and exercise, clean up their homes and pay their bills, spend some happy time with friends and family and try to rebuild their lives.

This is one of the key differences between chronic pain and other health problems, and one reason why long wait times are such a critical problem. It is far more difficult to help a person overcome pain when they are also struggling with having lost their job, lost touch with their friends, become estranged or divorced from their spouses and children, and dealing with the accumulated consequences of years of poor sleep, physical inactivity and medication side-effects. Chronic pain is more than a medical problem. It destroys people’s lives and affects entire communities.

Our team delivers a number of therapies that we all believe in and think are really helping patients. Our providers include TCM practitioners, nurses, international medical doctors (IMDs) and research associates from the Neuroscience program at Carleton University. We treat pain and the brain using a combination of treatments that is based on each patient’s needs. Our protocols may include EEG biofeedback, vision exercises, manual therapy, acupuncture of the body, ear and scalp, natural health products and laser therapy.

Most of the patients they see have symptoms associated with a motor vehicle accident. We decided to take the plunge and begin submitting treatment plans to auto insurers to help patients get the treatment they need. While we don’t love the paperwork, we all feel that we provide an important service to a population with

significant unmet needs. We also became fascinated by their problems.

We began seeing post-MVA patients referred for chronic pain disorders, but it was obvious to me that many of them had post-concussion syndrome and post-traumatic stress disorder, sometimes diagnosed and sometimes not. This is described as the Polytrauma Clinical Triad (PCT) in the published literature, in a single paper on US military veterans. We think we are seeing it in MVA patients, and this is supported by questionnaire data that we hope to publish soon.

While I have seen very gratifying results in my practice, it is clear that the way forward for integrative pain management has to be evidence-based. For many reasons, I think that measuring outcomes is more practical and relevant than conducting clinical trials.

As such, we have launched a project to develop mobile tools to help measure outcomes in these patients. We are calling it the BEAM project (Bringing Evidence to Alternative Medicine), and hope to have some useful tools to share soon.

My first career in medicine was as an ER physician. In 2004, I took a break to travel the world and it was then that I began learning about ‘alternative medicine’. After over a decade of clinical practice, I still love what I do. And I believe more than ever that integrative pain management will play an increasingly important role in the healthcare of the future.