Research Update articles are produced in order to keep practitioners up to date on impactful research that is relevant to the field of integrative medicine. These articles may contain summaries of recent studies, events, or other industry news that advances current knowledge and standards of care. The following article summarizes the research conducted by Hassan et al. titled, “Does integrative medicine reduce prescribed opioid use for chronic pain? A systematic literature review,” which was published in the journal Pain Medicine in 2019. (2)
Background
Chronic pain is both a public health concern and a major driver for opioid prescribing. Approximately half of individuals experiencing persistent or chronic pain seek opioids for treatment. (1) The decision to prescribe opioids for chronic pain has gained more attention for several reasons: firstly, research has shown decreased efficacy of opioids when used as a treatment for chronic pain compared to acute pain; secondly, the misuse, addition, and rise in accidental overdoses of opioids have led to the current “opioid crisis”; and thirdly, chronic pain is complex in nature and thus opioids may fail to address important aspects aside from physical symptoms, such as mental, emotional, and social factors. (1)(3) Due to these three reasons, holistic alternatives for pain management have gained attention. This article explored the efficacy of integrative medicine for reducing the need for opioid prescriptions in patients suffering from chronic pain.
Methods
This study was a systematic review achieved by completing a thorough online search of research databases. Chronic pain was defined as “persistent pain, lasting for more than three months beyond the time needed for tissue healing.” This review included studies with empirical data on the effectiveness of reducing opioid use. Participants had to be 18 years or older in addition to currently experiencing the aforementioned definition of chronic pain. Only integrative medicine interventions with at least one complementary and alternative medicine (CAM) therapy (e.g., cognitive behavioral therapy (CBT), meditation, acupuncture, etc.) administered in conjunction with pharmacological treatment were included.
CBT is a form of integrative medicine that can be helpful for many conditions, including chronic pain.
Results
A total of 5,162 citations were retrieved from MEDLINE, Embase, CINAHL, PubMed, and AMED databases. After all duplicates were removed, 23 studies met the inclusion criteria. Of those, eight were randomized controlled trials (RCTs), seven were retrospective studies, four were prospective observational studies, three were cross-sectional, and one was quasi-experimental. In examining the 23 studies by type of CAM therapy researched, there were six on multidisciplinary intervention, three on CBT, seven on cannabinoids, two on acupuncture treatment, two on educational support for opioid tapering, one on mindfulness-oriented recovery enhancement, one on therapeutic interactive voice response (TIVR) intervention following CBT, and one exploring the modality of physical therapy. In the six multidisciplinary studies, interventions included but were not limited to CBT, biofeedback and relaxation, health education, and occupational therapy. Five of the six studies were three weeks in duration with follow-up occurring three to six months post treatment, whereas one study lasted for six months in duration with no follow-up. Five of the six studies resulted in significant clinical improvements in all measured outcomes, including pain severity, depression, and anxiety. One study failed to produce reduction in opioid use, though the participants reported improvement in well-being, sleep quality, and reduced pain intensity. Both CBT and TIVR showed significant improvements as treatments. In the three CBT studies, all resulted in significant improvement in outcomes of pain, function, and psychological health, and two of the three led to a significant decrease in opioid medication use. TIVR is a four-component therapy following CBT consisting of a daily self-monitoring questionnaire, a review of coping skills, a prerecorded rehearsal of coping skills, and feedback messages personalized by the CBT therapist. TIVR decreased pain, depression, and opioid usage while also improving function and coping. In the seven cannabinoid studies, three were prospective observational studies involving a self-reported online survey, two were cross-sectional studies also involving online surveys, and two were retrospective studies that analyzed the possible correlation between cannabis and decreased opioid use. All three types of studies resulted in findings consistent with reduced daily opioid use or cessation from opioid use compared to the control with the exception of one study that failed to find a relationship between cannabis and pain or cannabis and opioid use. The remainder of the studies generally produced positive findings. In the two acupuncture intervention studies, one resulted in decreased pain medication use and increased relief of pain, functional ability, and quality of life in the one-year follow-up after receiving four treatments. The other study involved electroacupuncture for a duration of six weeks, resulting in reduced opioid medication use. The mindfulness-oriented recovery enhancement RCT resulted in decreased pain severity, functional interference, and desire for opioids post treatment, and the two education and opioid-tapering support studies resulted in a lack of increase in opioid use and improvement in pain interference, self-efficacy, and perceived opioid issues. Interestingly, the retrospective physical therapy study demonstrated decreased pain medication use during and following the therapy in all pain medications except opioids.
Critical analysis
Of the studies included in the systematic review, 87% produced statistically significant improvements in measured outcomes of either opioid cessation or reduction of use, including decreased desire for opioid use, decreased pain severity or interference, and increased ability to function and quality of life. Moreover, 60% of the studies with statistically significant results demonstrated that the intended outcomes continued after the six- to 12-month follow-up. One should note, however, that in analyzing the studies with the Mixed Methods Appraisal Tool, the actual quality of the methods used was low, with only 30% of the studies being RCTs and not all being fully blinded in nature. Small sample sizes and low response rates to surveys were also limitations, as both can greatly impact the validity of results. About half of the studies failed to report quantitative information on the opioid intake of the participants, and less than 25% of studies confirmed the reported reduction of opioid intake via methods such as urine drug tests or patient chart reviews. Another major limitation of the study was that only articles written in English were considered.
The bottom line
The opioid crisis and complex nature of chronic pain invite other treatment options for evaluation and consideration. As a holistic approach, integrative medicine demonstrates great potential in solving both aforementioned problems. In this study, the majority of the research included statistically significant positive findings across all measured outcomes. Strengths of this review include the variety of modalities examined and, in many cases, the longevity of the follow-up, ranging from up to six to 12 months. However, weaknesses of the study include its lack of opioid consumption quantity verification, low numbers of RCTs, and low survey responses, which should all be taken into consideration as well. This review serves as preliminary evidence of the efficacy of CAM and integrative medicine on opioid use in patients suffering from chronic pain, though more research is required to further elucidate these claims.
- Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., Dana, T., Bougatsos, C., & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of internal medicine, 162(4), 276–286. https://doi.org/10.7326/M14-2559
- Hassan, S., Zheng, Q., Rizzolo, E., Tezcanli, E., Bhardwaj, S., & Cooley, K. (2020). Does Integrative Medicine Reduce Prescribed Opioid Use for Chronic Pain? A Systematic Literature Review. Pain medicine (Malden, Mass.), 21(4), 836–859. https://doi.org/10.1093/pm/pnz291
- Tyndall M. An emergency response to the opioid overdose crisis in Canada: a regulated opioid distribution program. CMAJ. 2018;190(2):E35-E36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5770249/