“The US has 4.6 per cent of the world’s population. We’re using 80 per cent of the opioid supply, 99 per cent of global hydrocodone — and we’re still in pain.” — Arya Nielsen, Ph.D.
The problem of opioid addiction appears as a many-tentacled monster, eating our young people alive, as the Woodstock community became aware two years ago when several local men died of heroin overdose. Amidst the angst and sense of helplessness, it was clear that one of the culprits was the overprescribing of opioid painkillers, which can lead to heroin use.
According to the U.S. Department of Health and Human Services, 116 people die each day from opioid-related drug overdoses. Nearly 80% of heroin users reported misusing prescription opioids prior to taking heroin. Over 50% of chronic opioid use begins with opioids prescribed for inpatient acute pain.
As of January 1, 2018, hospitals accredited by the Joint Commission were required to offer patients nonpharmacologic methods of pain relief, including acupuncture therapy, massage therapy, or physical therapy, as well as relaxation response therapies that have been shown to be effective for acute pain. This shift in policy was largely instigated by the work of Woodstock resident Arya Nielsen, PhD, a researcher, teacher, and writer.
Nielsen practiced acupuncture in Woodstock for 25 years but is now focused on education and research at Icahn School of Medicine at Mount Sinai in New York City, where she has participated in studies that demonstrate the effectiveness of acupuncture for acute and chronic pain. Such research has been critical to convincing the medical system to incorporate acupuncture therapy in treatment strategies — even while many currently used treatments have not been thoroughly studied. “Only about half of what’s delivered in a western clinical encounter has been proven effective,” Nielsen said. “Often medicine moves forward on consensus, not science.”
In 2000, The Joint Commission (TJC), the country’s largest hospital accreditation organization, determined that pain was being under-treated and required doctors to ask their patients about pain. As part of the accreditation process, hospitals are scored on how consistently they conform to specified standards. While TJC, in its 2000 protocol, included nonpharm pain relief as a recommendation, its use was never scored when a hospital’s performance was scrutinized. Nielsen and fellow researchers asked TJC to start scoring effective nonpharm pain treatments.
Their request was made in 2013. Although the policy change took five years to implement, Nielsen doesn’t blame TJC for the delay. Her colleague for 20 years, research director Benjamin Kligler, M.D. — the brother of Rabbi Jonathan Kligler of the Woodstock Jewish Congregation — cautioned her not to be disappointed if it took months to receive a reply to her initial letter. In fact, TJC surprised them by responding the same day. Implementing the change, however, was complex.
TJC’s first step was to clarify its policy, pointing out that it had recommended nonpharm pain treatment since 2000 and was now prepared to step up its endorsement through scoring a hospital’s performance in this area. Nielsen and her team provided extensive literature reviews on all evidence-based nonpharm therapies to support the new policy. “TJC wrote their original pain mandate with the National Pharmaceutical Council,” she said, “so we wondered if there was going to be any pressure there. We were looking for a seat at the table, but pharma not only has several seats at the table, they ‘own’ the table.” Although the process of change moved at a glacial pace, there was increasing support from other professional and patient advocacy groups, whose members wrote in during the comment period to say how essential they considered the change. In 2017, the American College of Physicians came out with a recommendation that nonpharm therapies be considered the first line of care for acute, sub-acute, and chronic back pain.
Nielsen cited research showing, for instance, the benefits of providing acupuncture treatment before and after surgery. She explained, “Acupuncture will reduce pain, and is opioid sparing — you need less medication to manage severe pain. Acupuncture will also reduce anxiety and depression, nausea and vomiting, retention of urine, constipation, itching and other opioid side effects. And people become more engaged in their recovery. You get all this bang for your buck. And yet that treatment is not across-the-board paid for by insurance companies — but opioids are.”
One study looked at 300 emergency room patients who presented with acute pain. Half were randomized to have acupuncture, while the other half were put on intravenous morphine, which is commonly given in the ER. “They were looking for a pain score reduction of 50 percent,” said Nielsen, “which was reached by 92 percent of the acupuncture patients and 78 percent of the people on IV morphine. The time it took to get to pain relief was eight to 24 minutes with acupuncture, 14 to 42 minutes with morphine.” Furthermore, only 2.6 percent of the acupuncture patients experienced any adverse effects, as opposed to 56.6 percent of the morphine patients.
“People with chronic pain who are being maintained on opioids know that their doctors are working to respond to their pain,” said Nielsen. “But they should also know there are options to get off opioids, manage chronic pain, and become more active in their lives. And there are well-trained practitioners locally — many of whom I helped train.” Nielsen has taught at several acupuncture colleges in New York.
One of the advantages of acupuncture and other nonpharm modalities is a healing effect on the issues underlying the pain. Ninety percent of the benefit of a single course of acupuncture treatment for chronic pain has been shown to persist at one year. One of the disadvantages is that hands-on methods are not currently reimbursed to the extent that medications are, including opioids. In the case of acupuncture, group sessions can allow a practitioner to treat a number of patients simultaneously, since needles are typically left in for a period of time. Patients pay less for a group session while still having access to individually focused care.
Under a three-year grant from the Patient Centered Outcome Research Institute (PCORI) a part of the Affordable Care Act, Nielsen, Kligler, and their colleagues studied the effectiveness of group acupuncture sessions in the Bronx, the poorest congressional district in the U.S. The success of group treatments showed that they can expand access to service, making it more reasonably priced for people with low income in underserved settings. Several local acupuncturists offer group sessions, including Woodstock Healing Arts on Mill Hill Road and Julia Rose in Phoenicia. Patients may ask their acupuncturists if group treatment is available.
Insurance companies are beginning to catch up with nonpharm research and cost benefit. Nielsen co-wrote a “white paper,” a scholarly account of the research, to give insurance companies the evidence they need to justify coverage for effective nonpharm modalities, which some companies now do. A recent cost benefit study found that including nonpharm methods in treatment at a pediatric pain clinic reduced ER and inpatient insurance costs by $11,000 per patient per year, with hospital cost savings of $36,000 per patient per year.
Patients should call their insurance company to see if acupuncture and other nonpharm therapies are covered. Nielsen said Medicaid and Medicare do not currently pay for acupuncture therapy or massage therapy, but they have been asked to review coverage as an option.
Many doctors, overworked and deluged with information, do not yet know about the change in TJC policy. In many cases, it’s up to patients to open the conversation or to request a referral to nonpharm practitioners. “Many patients have become passive consumers, with the expectation that surgery and pharmaceuticals will solve their problems,” said Nielsen. “They’ve been trained to think that way, but there’s so much patients can do to advance their health.”
Patients who want to refer their doctors to the research on effectiveness of acupuncture therapy, as well as other evidence-based nonpharmacologic strategies, may direct them to the white paper at www.nonpharmpaincare.org