Complementary and Alternative Pain Management, Part 1

Definitions

• “Complementary” generally refers to using a nonmainstream approach together with conventional medicine.
• “Alternative” refers to using a nonmainstream approach in place of conventional medicine.
• Integrative health care emphasizes a holistic, patient-focused approach to health care and wellness, often including mental, emotional, functional, spiritual, social, and community aspects. Integrative health care often brings conventional and complementary approaches together in a coordinated way.

Safety

• Certain dietary supplements and natural products can affect cytochrome P450 isozymes and intestinal p-glycoprotein. For example, St John’s wort can reduce the efficacy of medications that are metabolized by cytochrome P450.
• Some Chinese herbal supplements can cause nephropathy and liver toxicity.
• Acupuncture and massage are safe when performed by experienced providers. However, there is always the risk of puncturing internal organs, such as causing a pneumothorax, and injury to nerves, muscles, ligaments, and vessels when performed inappropriately.
• Mindfulness, mediation, relaxation and biofeedback are considered safe, but the research on their safety is limited.

Acupuncture

Promising results have emerged that acupuncture can provide pain relief when used alone or as an adjunct to other conventional treatments for low back pain, headache, and fibromyalgia.

• Lower back pain. Acupuncture provides immediate improvement in lower back pain, but the intermediate and long-term effect is less clear.
  • A 2017 meta-analysis concluded that acupuncture is effective for the treatment of chronic musculoskeletal pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain.¹
• Headaches. Acupuncture decreases the frequency of both migraine and tension-type headaches.
  • According to a Cochrane review published in 2016, acupuncture was associated with a small but statistically significant frequency reduction over sham in migraine.² In another review published in the same year, participants receiving acupuncture for tension-type headaches showed a decreased frequency of tension-type headaches compared to the sham group.³
• Irritable bowel syndrome (IBS). Acupuncture can improve IBS-related symptoms and functional outcomes, but it is not better than the sham control.
  • In a 2009 clinical trial, there was no statistically significant difference between acupuncture and sham acupuncture on the IBS Global Improvement Scale. Both groups improved global symptoms significantly compared with the waitlist control group.⁴
  • Fibromyalgia. Recent studies have provided encouraging evidence that acupuncture may help relieve some fibromyalgia symptoms.
  • In a 2013 Cochrane review, the authors concluded that there is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia. There is moderate level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue or improving sleep or global well-being. Electrical acupuncture is probably better than manual acupuncture for pain and stiffness reduction and improvement of global well-being, sleep, and fatigue. The effect lasts up to one month but is not maintained at the six months follow-up.⁵

Meditation and Mindfulness

Studies examining the effects of mindfulness or meditation on acute and chronic pain have produced mixed results.

• In 2017, a systemic review and meta-analysis of 38 randomized control trials (RCT) found low-quality evidence that mindfulness meditation is associated with a small decrease in pain and found statistically significant effects for depression symptoms and quality of life.⁶
• In another meta-analysis of mindfulness for chronic pain, 11 studies were included addressing a variety of chronic pain conditions, including fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, failed back surgery syndrome, and mixed etiology. This systematic review found limited evidence for the effectiveness of mindfulness-based interventions in chronic pain. Individual studies were generally small, and results for most outcomes were not statistically significant. A meta-analysis revealed that mindfulness-based interventions may have a positive impact on perceived pain control with a moderate effect size, but there was no evidence of a benefit in terms of clinical outcomes such as pain intensity or depression.⁷

Aromatherapy

Aromatherapy refers to the medicinal or therapeutic use of essential oils absorbed through the skin or olfactory system. Two systemic meta-analyses found that aromatherapy is effective in alleviating acute nociceptive pain, mainly obstetrical and gynecological pain, and postoperative pain.

• A systematic review and meta-analysis of 12 studies of aromatherapy for various painful conditions revealed a significant positive effect of aromatherapy in reducing pain reported on a visual analog scale. Secondary analysis showed that aromatherapy is most effective in treating acute nociceptive pain related to obstetrical and gynecological conditions and postoperative pain.⁸
• A narrative synthesis of findings of 26 systemic reviews concluded that there is moderate evidence for aromatherapy in alleviating pain in dysmenorrhea and pain during delivery. It is also potentially beneficial in improving stress, depression, anxiety, and sleep among various populations, with low to moderate confidence in the evidence.⁹

Hypnosis

Multiple meta-analyses have shown that hypnosis can reduce pain intensity and pain-related interference. But the efficacy is influenced by the hypnotic suggestibility and the number of sessions.

• A meta-analysis of 45 trials of hypnosis showed that it reduced 70% more pain in the treatment group than in the control group. Hypnosis was moderated by hypnotic suggestibility. The authors concluded that hypnosis is a very efficacious intervention for alleviating clinical pain.10 Similar findings were noted in another meta-analysis, in which 85 controlled experimental trials with 3,632 total participants were analyzed. The authors found that hypnosis is efficacious in improving pain ratings, threshold, and tolerance. The efficacy is strongly influenced by hypnotic suggestibility and the use of direct analgesic suggestion.¹¹
• Another meta-analysis of nine RCTs 530 total patients with chronic musculoskeletal and neuropathic pain showed a moderate decrease in pain intensity and pain interference following hypnosis compared to control interventions. A significant moderate to large effect size of hypnosis compared to controls was found at eight sessions or more, compared to a small and not statistically significant effect for fewer than eight sessions. These findings suggest that a hypnosis treatment lasting a minimum of eight sessions could offer an effective complementary approach to manage chronic musculoskeletal and neuropathic pain.¹²