For Some, Recent Safety Concerns About Pain Relievers Are Heightening Interest in Drug-Free Treatments, Many of Them Promising But Still Largely Unproven.
By January W. Payne
Washington Post Staff Writer
Tuesday, January 4, 2005; Page HE01
Gwenn Herman knows chronic pain — the regular backaches, the stiffness and freezing of her neck after her 1995 car accident, the pain that didn’t respond, or responded inconsistently, to prescription and nonprescription painkillers. That’s why she learned, long before last month’s rash of safety alerts about three commonly used pain medications, to explore alternative treatments like meditation, guided imagery and breathing exercises. Today, she teaches the techniques, all of which she uses daily, to members of support groups sponsored by the Pain Connection, a Potomac-based nonprofit organization she runs.
“What works for one person doesn’t work for another,” said Herman. “The more alternatives, the better.”
That view is likely to find more adherents following last month’s crush of sometimes-conflicting reports linking the highly advertised pain drugs Vioxx and Celebrex and, more recently, the popular over-the-counter painkiller Aleve (naproxen) to potentially life-threatening side effects. The safety concerns led to Vioxx’s removal from the market at the end of September and the halting of a major clinical trial for Celebrex last month.
Experts advise patients not to stop pain medications without consulting their doctor, noting that further analysis of the data is needed and acceptable health risks must be evaluated individually. The drugs now subject to so much publicity may remain the best choices for some patients. Nonetheless, the reports have focused more attention on alternative pain relief treatments, particularly those that don’t involve drugs.
Palliative effects for some of these techniques, like meditation, have been shown in several studies. Some other methods, like guided imagery, so far tend to rest on more anecdotal evidence.
“I find [guided imagery] extremely helpful in controlling my pain,” said Herman. “The images that I use helps give an outlet to the pain and a pathway out of my body.”
Still waiting to be established is to what extent any of the treatments can effectively relieve the chronic, often daily pain of those with such conditions as arthritis, severe headaches, lupus and fibromyalgia.
Pain sufferers confused or upset by recent painkiller news got a small dose of hope last month from a study funded by two branches of the National Institutes of Health: the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the National Center for Complementary and Alternative Medicine (NCCAM).
That study found that acupuncture — a 2,000 year-old Eastern practice that involves the insertion of thin needles at specific points on the body — appeared to help relieve pain and improve function for patients with knee osteoarthritis.
The large study, published in the Annals of Internal Medicine, assigned about 190 of 570 patients ages 50 and older to receive acupuncture. By week eight, these participants functioned better than those receiving sham acupuncture or educational therapy. By week 14, those who were getting acupuncture reported less pain than the others, but the sham treatment group also reported pain reduction, though at a slightly lower level.
Researchers plan to analyze the data to see if the pain relief from acupuncture was sufficient to reduce or eliminate the need for pain medications.
From clinical experience, that’s what we do think is happening,” said study author Brian Berman, director of the University of Maryland School of Medicine’s Center for Integrative Medicine. “They may need less of the medication, which may mean less side effects.”
Beyond special pain treatments, there are other basic steps that doctors and experts say may help ease patient pain. Weight loss, for example, can help relieve the pressure on arthritic joints, according to NIAMS. Andrew Weil, professor of internal medicine and director of the Program in Integrative Medicine at the University of Arizona, tells patients a diet low in “pro-inflammatory fats” such as margarine can also help ease arthritis pain.
Several non-drug approaches besides acupuncture that some doctors regard as helpful — or at least promising — are listed below. But there’s an important caveat: Even non-drug treatments can be dangerous. Some treatments can interact with prescription and over-the-counter medications. Excessive doses of supplements may cause harmful side effects. And pursuing alternative treatments in place of necessary conventional care can create additional dangers. Experts advise against stopping or starting any therapy — traditional or alternative — without first consulting a physician.
Meditation: one of the most commonly used mind-body therapies, meditation has been shown to increase activity in parts of the brain associated with positive emotional states, according to NCCAM. Some studies suggest meditation may relieve pain from arthritis and other conditions, but the pain relief reported by participants could also have resulted from other therapies they were receiving. Clinical trials are investigating the pain-relieving effects of meditation on patients with rheumatoid arthritis and other chronic conditions.
Biofeedback: this technique teaches patients to control functions such as heart rate, muscle tension, breathing, skin temperature and blood pressure to relieve stress and chronic pain. Sensors track changes in pulse, skin temperature and muscle tone, among others, and signal patients. Biofeedback therapists teach patients how to recognize such changes on their own. Biofeedback has been shown to be helpful in treating about 150 medical conditions, including migraines, arthritis and fibromyalgia, according to the Mayo Clinic.
Hypnosis: “You can learn to change the perceptions of pain,” Weil said. An NCCAM-funded clinical trial is exploring whether hypnosis and other nontraditional therapies can ease muscle tension in children with spastic cerebral palsy. Studies suggest a benefit from hypnosis for patients with many different types of pain, including low back, tension headache, osteoarthritis and chronic pain. But larger, better-designed studies are needed to confirm early findings, according to Harvard Medical School, through its online partner Aetna InteliHealth.
Cognitive behavioral therapy: “Thoughts and emotions can affect pain,” Berman said, so cognitive behavioral therapy — a kind of talk therapy that helps people recognize and change negative behaviors — may help relieve the depression, stress and chronic pain that can accompany disabling diseases. Duke University researchers have developed a talk therapy program for arthritis patients and their spouses to see if this helps patients cope with the disease. They are exploring whether patients’ aerobic fitness or coping abilities decrease their pain or disability.
Exercise and movement therapy: a regular program of physical movement is sometimes helpful in relieving pain. But patients should use care when selecting a workout regimen, as overexertion can cause additional pain, according to NIAMS. Light exercise regimens, physical therapy, pool exercise and “movement therapies” such as tai chi are recommended as good starting points for many patients.
Osteopathic manipulation Manipulation of the joints “restores the normal range of motion of a particular joint, [and] can restore the normal blood flow and drainage to an area,” said Martin Levine, an osteopathic physician in New Jersey and a member of the board of trustees for the American Osteopathic Association. Growing evidence suggests that osteopathic manipulation may ease low back pain and may be useful for a variety of other conditions, including depression, fibromyalgia, menstrual pain and neck pain, according to Harvard.
Chiropractic treatments: spinal manipulations, focusing on the relationship between the body’s structure (primarily of the spine) and function, are mainly used to treat musculoskeletal conditions. Evidence of benefits from chiropractic treatments varies with the condition being treated. Harvard counts at least 150 published studies or case reports on chiropractic manipulation therapy for patients with low back pain, but many are poorly designed and results are mixed. Several studies have also shown pain relief for patients with tension or migraine headaches, but most of these studies were also poorly designed, according to Harvard.
Massage: the stroking or kneading of sore muscles by a therapist can increase blood flow to painful areas, sometimes providing relief, according to NIAMS. But arthritic joints are sensitive, so patients should go to a therapist trained in handling the disease. Some studies suggest improvements in low back pain from massage techniques, though most of the studies were not well designed, according to Harvard. Preliminary research also shows that massage may help relieve chronic pain from musculoskeletal conditions. But more studies are needed to confirm the results.
Herbs and Supplements
Glucosamine and Chondroitin Sulfate: “There’s a fair amount of evidence that shows that [supplements containing glucosamine and chondroitin] can help, especially for arthritis pain and inflammation,” Berman said. The cartilage building blocks — glucosamine is a glucose derivative that some experts believe may help cartilage form and repair itself; chondroitin sulfate is part of a large protein molecule that gives cartilage elasticity — are made into supplements from shellfish and other animal tissue. A study sponsored by NCCAM and the Department of Veterans Affairs is exploring whether this combination treatment is more effective than placebo in treating osteoarthritis of the knee. The study will also look at whether either supplement alone is more effective than the combination.
Omega-3 Oils: There is some evidence that capsules containing these oils may reduce pain, inflammation and stiffness associated with rheumatoid arthritis, but not osteoarthritis, according to Harvard. An NCCAM-funded study is investigating whether a combination of fish oil and borage seed oil may work better for rheumatoid arthritis than either oil alone.
Turmeric and Ginger: Dr. Weil calls the combination, available as a supplement, a “very effective herbal anti-inflammatory [that] works as well as NSAIDs [nonsteroidal anti-inflammatory drugs].” But the Mayo Clinic finds little evidence to support an anti-inflammatory benefit. NCCAM is funding a study to see if these botanicals reduce inflammation associated with arthritis and asthma. It’s also funding a center at the University of Arizona to investigate their benefits.
Heat/Cold Therapy: applying heating pads or cold packs to sore joints and muscles may ease pain temporarily. But arthritis patients should consult their doctors or physical therapists because the recommendation for cold or heat varies with arthritis type, according to NIAMS. Moist or dry heat or an ice pack can be placed on the sore area for about 15 minutes to relieve pain. Patients with poor circulation should not use cold packs, according to NIAMS.
Transcutaneous Electrical Nerve Stimulation (TENS): the wearing of a small, portable electric stimulation unit may help ease pain temporarily, according to NIAMS, by blocking pain messages to the brain and modifying pain perception. The unit sends mild electric pulses to nerve endings under the skin in the painful area.
Source: The Washington Post. © 2005 The Washington Post Company.