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Almost half of Veterans experience chronic pain, making it the most common condition for Veterans seeking care within VA. Additionally, 15 percent use opioids after combat.1 These rates are much higher than those seen in the general population, which is experiencing an opioid “epidemic,” as underscored by a continued rise in opioid-related deaths.
In response to these concerns, VA Secretary McDonald committed VA and HSR&D to the White House to lead the examination of non-opioid alternatives to pain management. To fulfill this commitment, HSR&D sponsored a small, one-day expert meeting in April 2016 to plan for a November 2016 State of the Art (SOTA) meeting. To prepare for the expert meeting, the VA Evidence Synthesis Program (ESP) conducted a rapid review of the literature evaluating the effects of complementary and integrative health (CIH) therapies on opioid use, while a second group of CIH and pain researchers reviewed the literature on the effects of CIH on pain. The November 2016 SOTA will evaluate evidence about the effectiveness of non-opioid therapies (including but not limited to CIH) for pain, and identify promising practices, operational barriers, and a research agenda on nonopioid therapies for pain.
CIH (formerly “CAM,” or complementary and alternative medicine) includes yoga, meditation and acupuncture—all of which are emerging non-pharmacologic options that might effectively address pain with fewer of the risks or side effects associated with traditional medical therapies.
The Institute of Medicine and others report patients often use CIH therapies because they prefer non-pharmacological self-management options or experience unwanted side effects or lack of response with pharmacologic and other commonly offered approaches. CIH therapies appear acceptable not only to Veterans, but also to active duty troops, with 29 percent of military treatment facilities offering CIH approaches through 275 programs in total. CIH therapies were also recommended in the Office of The Army Surgeon General’s 2010 Standardized DoD and VHA Vision and Approach to Pain Management.
Over 2,000 randomized controlled trials on CIH have been reported in the Englishlanguage scientific literature.2 In 2014, VA’s ESP conducted four reviews of systematic reviews and found yoga, tai chi, mindfulness, and acupuncture have “strong” or “promising” effects on pain.3 For example, the VA ESP found evidence of a positive or a potentially positive effect of acupuncture on chronic pain, headaches, pain in general, and osteoarthritis pain. They found yoga had been studied most extensively for low back pain and showed consistent shortterm benefits for that pain.
Clearly, the effectiveness of CIH therapies on pain might not translate to its deterrence or reduction of opioid use, but that can be better understood through an examination of the literature and relevant intervention studies. Patients can easily become addicted to opioids, and that addiction is not likely to be broken through meditation, acupuncture, or yoga. However, busy clinicians are often overwhelmed by patients with pain, and prescribing drugs can be a quick solution when non-pharmacologic options are poorly provisioned. Appropriately resourced CIH might contribute to patientcentered self-management and offer busy clinicians a feasible alternative to opiates for patients’ pain.
Are CIH therapies cost-effective approaches to addressing pain? We should have an initial answer in late 2017 from our cost-effectiveness analysis of several types of CIH therapies on musculoskeletal pain. However, a breathing meditation program was shown by Stahl and colleagues (2015) to result in an average 43 percent reduction in billable encounters.
Given the potential for CIH to improve Veterans’ health and the patient-centeredness of care, the recently-passed 2015 U.S. Omnibus budget called for the expansion of research and education on, and delivery of, CIH to Veterans. CIH figures prominently in several recent VA initiatives, including VA’s Blueprint for Excellence (as the focus of needed research under strategy 7j), the 2015 MyVA Integrated Plan, and a VA Office of Patient Care Services’ PACT Pain Roadmap.
CIH therapies are offered throughout VA. In fact, a recent survey conducted by the VA Healthcare Analytics & Information Group found 82 percent of facilities offered some type of mindfulness or meditation, 73 percent offered yoga, 60 percent offered acupuncture, 49 percent offered Tai Chi/QI Gong, and 37 percent offered chiropractic care.
CIH holds promise as a Veteran-centered approach to improving pain. VA has an opportunity to strengthen the evidence base for CIH as a pain intervention, and understand how CIH impacts pain, the patient- centeredness of the care experience, and provider experiences and approaches including opioid use.
1. Toblin R.L., Quartana P.J., Riviere L.A., Walper K.C., Hoge C.W. “Chronic Pain and Opioid Use in US Soldiers after Combat Deployment,” JAMA Internal Medicine 2014;174(8):1400-1.
2. Elwy A.R., Johnston J.M., Bormann J.E., Hull A., Taylor S.L. “A Systematic Scoping Review of Complementary and Alternative Medicine Mind and Body Practices to Improve the Health of Veterans and Military Personnel,” Medical Care 2014; 52(12 Suppl 5):S70-82.
3. Available at: www.hsrd.research.va.gov/publications/esp/cam_mindfulness.cfm