Pain Medication: Risks and Alternatives

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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The proof that acupuncture and herbal medicine does have sufficient evidence-based effects to treat chronic inflammatory conditions, and other medical conditions that cause pain

In 2010, the U.S. Army Surgeon General, Lt. Gen. Eric B. Schoomaker, announced that acupuncture had met the highest standards of proof of scientific efficacy and was proving to be a valuable tool in treating chronic pain and reducing dependency on pain medications for soldiers and veterans. A 2013 interview with Dr. Sanjay Gupta, aired on CNN, showed the Army Surgeon General and other officers describing the proven benefits of acupuncture, even for soldiers and officers who were completely skeptical. In 2012, Dr. Andrew Vickers, a renowned health outcomes researcher at Memorial Sloan-Kettering in New York, published a definitive meta-review of these studies in the Annals of Internal Medicine. Dr. Vickers chose only the human clinical studies with the highest possible rating, and found that in these 29 studies, involving more than 18,000 patients with chronic pain, that acupuncture stimulation definitely outperforms the chosen sham or placebo significantly, and more importantly, outperforms standard therapy for chronic pain even more significantly than it outperforms placebo. Dr. Vickers stated that this meta-review should change the attitude in standard medicine and prompt M.D. referrals for patients with chronic pain. There is no longer any scientific doubt of efficacy. To see the study summary click here: http://www.ncbi.nlm.nih.gov/pubmed/22965186 .

Finding the courage to actually conduct and publish serious studies of herbal medicines that could potentially compete with the lucrative market in pain medications has been even more problematic than for acupuncture itself, but the times they are a'changing. For instance, in 2010, experts at the University of Pittsburgh Medical Center and Vanderbilt University, in Pittsburgh, Pennsylvania, and Nashville, Tennessee, U.S.A. released a meta-review of the small number of highly studied herbal and nutrient medicines proven to treat pain with anti-inflammatory, or rather inflammatory modulating effects. This review explains how the now well-studied Boswellia serata (Ru xiang, or Frankincense Olibanum tree resin), Curcuma (Yu jin, E zhu, Jiang huang turmeric), Corydalis (Yan hu suo), Resveratrol (Hu zhang), Uncaria (Gou teng), Capsaicin, Pycnogenol (lignans in pine bark), green tea polyphenols and omega-3 essential fatty acids (krill oil) were all proven to benefit the inflammatory metabolism and relieve pain, along with other benefits for the tissues. To see this study, click here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3011108/ . A prior 2003 study at the University of Maryland School of Nursing and the University of Exeter School of Medicine, in the U.S. and U.K. detailed these same herbal medicines, and Trypterygium wilfordii (Lei gong teng) for the treatment of Rheumatoid Arthritis. To see this study, click here: http://rheumatology.oxfordjournals.org/content/42/5/652.full . A 2014 study at the University of California at Irvine showed that a chemical in the Chinese herb Corydalis yanhusuo, one of the main herbs used in formulas to treat pain traditionally, called DHCB (dehydrocarybulbine), dramatically decreased both inflammatory pain and neuropathic pain, which is very difficult to relieve with current pharmaceutical pain medicaton, and did not produce the tolerance with continued use seen with synthetic pain medications. Of course, the effects are dose-dependent, and most patients in the U.S. are reluctant to take enough dosage to relieve their pain effectively due to decades of negative advice on herbal medicine from standard medicine. UC Irvine has created a project to assemble an herbalome with reverse pharmacology to provide evidence of a broad array of Chinese herbal chemicals. We shall see whether this database survives, as other universities have created herbal phytochemical databases that were taken down in the last two decades: http://news.uci.edu/press-releases/chinese-herbal-compound-relieves-inflammatory-and-neuropathic-pain/ . These are just a few of the now many proofs of efficacy and safety of acupuncture plus herbal and nutrient medicine in treating pain and the underlying causes of pain, although we still see almost no integration of these therapies by standard medicine, and a continued persistence to discourage patient utilization.

Such a large number of scientific studies, both physiological, and clinical human trials using randomized placebo controls, now exist, that it is unlikely that any patient is now unaware of the proof of acupuncture in relieving of pain. The impression that acupuncture only provides temporary relief of pain, though, has become a mantra of standard medicine, despite a large amount of evidence to the contrary. Acupuncture is proven to exert a wide array of physiological effects, promoting endorphin pain relief as well as improving circulation, modulating inflammatory mediators, stimulating neuroendocrine effects, and improving many homeostatic mechanisms that our bodies use to effect tissue repair. The proven physiological effects of acupuncture are very broad. One of the key effects in pain relief, though, is the modulation of inflammatory mediation to promote improved tissue repair and maintenance, and achieve less stimulation of pain receptors with unhealthy concentrations of inflammatory cytokines in chronic painful conditions. Acupuncture stimulation in the medical specialty of TCM is meant to be combined with direct soft tissue physiotherapy, and biochemical medicine with herbal and nutrient medicines, to achieve a full restorative outcome, though. All of these integrated treatment modalities are now evidence-bases and proven to provide an amazing array of benefits. The only side effects with these TCM therapies is better overall health.

For too long standard medicine and medical doctors have only recommended therapy to temporarily relieve pain, not therapy to restore and heal the tissues that are causing this pain. Holistic medicine offers many therapeutic tools to correct the underlying causes of all types of pain and tissue injury and degeneration, as well as to help the body cope with the pain signals, chronic pain perception, and associated autonomic symptoms related to pain. Complementary and Integrative Medicine and Traditional Chinese Medicine (CIM/TCM) offer so much to help the patients get well, as well as to provide pain relief. The cynical denial of this wealth of safe and proven treatment protocols, insisting that the medical specialty only provides one therapeutic tool, and that it only achieves a short minor relief of pain, not a resolution to the tissue injury, must stop. Only the epidemic of injury and death from pain medication, and the failures of many surgical interventions in long-term outcomes has finally led the medical profession to start endorsing CIM/TCM.

A growing body of evidence from scientific study is confirming not only that acupuncture has proven efficacy to treat chronic inflammatory conditions, but how this needle stimulation works. Acupuncture is difficult to assess under the double-blind placebo-controlled conditions used to prove efficacy of corticosteroid pharmaceuticals, yet has been held to this standard. Creating an acupuncture placebo is problematic, and blinding both the administering physician and the patient to this so-called placebo versus real acupuncture has been a challenge. Acupuncture, in effect, has been held to higher standards of proof than any other manual therapy. Despite this, the NIH and WHO have reviewed evidence over decades and long ago declared that acupuncture is a proven evidence-based therapy for many chronic inflammatory conditions. Meta-analysis since then has shown that success in human clinical trials has been demonstrated in the treatment of rheumatoid arthritis, bronchial asthma, pruritic dermatosis, carpal tunnel syndrome, and other inflammatory disorders in humans and animals (SCOGNAMILLO-SZABO, BECHARA, 2001). Specific trials in recent years have confirmed the efficacy of acupuncture treatment on allergic rhinitis, bronchial asthma, eczema, rheumatoid arthritis, and other chronic inflammatory disorders (TOWNSEND et al 1999; TUMACHI 1999, CASIMIRO et al 2002, STERUER-STEYA, RUSSUB, STEURERC, 2002; BIELORY, HEIMALL, 2003, MADSEN et al 2003; MCCARNEY et al 2004). Each year clinical study is advancing and producing greater proof of the efficacy of acupuncture.

How does acupuncture control chronic inflammatory conditions? Since the inflammatory response involves a complex set of highly orchestrated events in the body, with a cascade of chemical mediators insuring a highly regulated and modulated effect, this is a difficult question to study. The initial response to tissue injury and disease is largely controlled by the hormone cortisol, which is constantly produced mainly by the adrenal glands in a controlled diurnal cycle. Many health problems, especially hormonal imbalances, can adversely affect the diurnal cortisol levels and responses. Corticosteroids are synthetic chemicals that mimic this hormonal inflammatory mediator. There are many other inflammatory mediators in the body besides cortisol. Prostaglandins and interleukins are inflammatory mediators that are inhibited by non-steroidal anti-inflammatories. The problem with these pharmaceutical approaches is that when the whole cascade of inflammatory mediators is not addressed by the therapy, and that severe inflammatory dysregulation can occur, with disastrous results. Since the inflammatory process is a beneficial process in the body, evolved to repair and maintain healthy tissues, inhibition of a part of the process can produce unwanted results. The trials of malpractice and medical injury concerning the anti-inflammatory COX2 inhibitor, Vioxx, revealed that chronic use of this medication resulted in perhaps 50,000 deaths related to inflammatory dysregulation. The promise of acupuncture is that is may stimulate the whole natural cascade of inflammtory mediators in the body, and thus avoid these dangerous and unwanted side effects.

A 2005 study on animals at University Medical Schools and Veterinary Schools in Sao Paulo, Brazil, (Szabo et al, Sao Paulo State University and University of Sao Paulo, Faculty of Medicine, funded by ELISA and FAPESP), investigated the more specific effects of inflammatory modulation with acupuncture. Previous studies had demonstrated that acupuncture significantly suppressed neutrophil migration to the site of induced inflammation in the peritoneal cavity of study animals. Neutrophils are white blood cells that are the main immune reaction to acute infection and inflammation, and the peritoneum is the lining of the abdominal cavity. It was found that this acupuncture effect was not mediated by corticoid adrenal hormones, because a drug that blocked the corticoid receptors, RU-486, did not interfere with the immune response. Three cytokines, or inflammatory mediators, tumor necrosis factor alpha (TNFalpha), interleukin-1 beta (IL-1beta), and interleukin 10, were measured. It was found that acupuncture stimulation from just 3 needles distally placed, significantly inhibited just the interleukin-1beta, an important cytokine that stimulates neutrophil migration in the inflammatory complement system in humans. The researchers found that acupuncture stimulation exerts a modulatory effect on inflammation, and that specific effects are probably also tied to specific acupuncture locations on the body. In this study, the sites were between the eyebrows, at the lumbosacral junction, and near the anus. As with all such studies, the choice of acupuncture points and stimulation was designed for simplicity, and was probably less effective than many clinical acupuncture treatments.

The implications of this study, and numerous other scientific studies of anti-inflammatory, or inflammatory modulation effects of acupuncture, are that acupuncture stimulation is now proven to have an array of effects that modulate chronic and acute inflammatory states, and that these various effects stimulate an improved natural response in the body to inflammation. These studies also imply that various types of point selection and stimulation techniques are proven to have specific effects. In short, the empirical evidence collected over centuries in China concerning the application of acupuncture are proving true, based on modern laboratory measurement and modern scientific method.

Research into the effects of acupuncture stimulation and its effects on chronic pain in recent years has focused on the modulation of pain perception in the central nervous system (CNS), though. The creation of various brain imaging devices, such as functional magnetic resonance imaging (fMRI), has led to the ability of science to see what part of the brain is being stimulated by specific acupuncture trigger points, revealing the ability of acupuncture needle manipulation and electroacupuncture to stimulate normalizing effects, or homeostasis, in the brain. Combined with analysis of chemistry in the blood, this has led to our ability to objectively quantify the modulation of the brain regarding pain sensation, as well as reaction to pain, in ways that were previously unimaginable. Both these specific in vitro and in vivo effects are now proven with many experiments and studies, but high quality human clinical trials that are randomized and controlled are accumulating to provide evidence that these therapies work in many ways. Much of this evidence is available in Additional Information with links to studies in this article, and other articles on this website.

In addition, a long history of myofascial trigger point needling is documented in TCM texts and clinical practice. Historically, this was called A shi needling, translated as "that's it", meaning that the patient indicates to the physician that they found the trigger point. Other terms used in historic literature also apply, such as trail needling, where the physician asks the patient where the trigger point symptoms radiate, and uses another needle in this trigger point along the dermatome or myotome. The acupuncture point locations are described as points along meridians and channels, as well as local points, and empirical points. While the public has been led to believe that acupuncture is limited to the shallow points noted as the main 365 point locations along 12 meridians, the TCM literature has much description of 6 types of meridians, with shallow to deep point locations that are determined by palpation, anatomy and triggering of a response (de qi). The types of meridians include broad tendon, ligament and fascial meridians that correspond to modern dermatomes and myotomes, as well as meridians that are described as a narrow line of points related to organs and the referred pain patterns of organ pathology. These referred pain patterns are analogous to the modern systems of dermatomes, myotomes, and referred organ patterns in the body, but predated the modern scientific theories by thousands of years. The use of myofascial trigger point needling is becoming widely accepted in standard medicine today as well, pioneered by the great Dr. Janet Travell, and documented by her colleague Dr. Simon. The acupuncture profession provides teaching of both the classic and modern theories and techniques. The scientific studies of myofascial trigger point needling and stimulation, as well as manual release, active release techniques, and even neuromuscular reeducation and other mind-body techniques researched in recent years directly applies to the practice of acupuncture and TCM.

These various acupuncture and physiotherapy modalities that are now extensively studied, undergoing randomized clinical human trials, and are proven, are also potentially combined in TCM practice with other proven treatment modalities that provide pain relief and resolve the underlying causes of pain. Anti-inflammatory effects of Chinese herbs are the subject of numerous well-funded studies and clinical trials in the United States, as well as China, many European countries, Japan, Australia, Brazil, etc. One only needs to go the U.S. Natiional Institutes of Health Pub-Med database to access many of these scientific studies. The important points we see elucidated in herbal studies are that the effects are dose dependant, that the choice and quality of herbs are important, and often that the extraction methods are important to achieve the correct chemicals. The way to insure that these objectives are achieved is by utilizing professional herbalists and their professional products. Most of these highly trained professional herbalists in the United States are Licensed Acupuncturists.

The lack of high quality randomized controlled human clinical trials, or RCTs, for herbal medicines in the treatment of pain is due to the problems inherent in accepted study design, not to the known clinical efficacy. These RCTs are designed to evaluate single and specific chemicals with specific effects measured, and Traditional Chinese Herbology has long used herbal formulas to achieve a broad array of synergistic effects to treat pain, which contain hundreds of active chemicals. In 2014, research at the University of California at Irvine showed how a specific chemical in the Chinese herb Corydalis Yan hu suo effectively relieves both inflammatory pain and the more difficult to treat neuropathic pain, and does not show the problems with increased tolerance, or diminished effects, with chronic use, that are inherent in pharmaceutical pain medications. This research project will use reverse pharmacology to assemble an herbalome database of specific herbal chemicals. To see an explanation from the University click here: http://news.uci.edu/press-releases/chinese-herbal-compound-relieves-inflammatory-and-neuropathic-pain/ . Hopefully, such research will not be suppressed like prior phytochemical databases in the United States, and lead to greater acceptance, healthcare payment for professional herbal prescription, and improved guidelines for effective dosage in the treatment of pain with Chinese Herbal Medicine (CHM).

The key point when examining scientific evidence of the anti-inflammatory effects of acupuncture and Chinese herbs is the difference between the use of steroidal and non-steroidal synthetic medicines and the effects of acupuncture and Chinese herbs. The pharmaceutical approaches are specific and allopathic, meaning that the chemicals are designed to alter specific mechanisms in the inflammatory cascade. Acupuncture and Chinese herbs have been shown to have similar effects, but in a modulatory and varied manner, stimulating areas of the complex inflammatory cascade that may not be working efficiently due to some health problems in the body. The chance of side effects with the latter approach are slim, and the possibility of restoring the patient metabolisms are great. The endproduct of therapy should be a healthier immune system with Complementary Medicine, whereas the chronic use of synthetic corticosteroids has been found to have negative effects on the whole system, especially in producing adrenal insufficiency, which would negatively impact the ability to respond to future inflammation and infection. As we see from the studies cited above, the use of NSAIDS, especially the ubiquitous acetaminophen, which is also found in almost all narcotic pain medication, also has a deleterious effect on the immune responses, linked to rising rates of allergic asthma, sinusitis and eczema. This is not to say that standard treatment is discouraged, as modern allopathic treatments may have a strong and dramatic effect, but a thoughtful assessment of risk versus benefit will bring the intelligent doctor and patient to the conclusion that thes modern allopathic treatment should be used only when needed, and with limited courses, not chronic dependence.

Integrating care with Complementary Medicine provides the patient with safe, effective, and problem-resolving therapies, and reduces the dependence on prolonged therapy and drug dependence. Effective integration of the many treatment modalities of Traditional Chinese Medicine (TCM) may speed recovery and repair of tissues, as well as adaptation to chronic pain. Shortening treatment time with integrative medicine will both allow the patient to get back to work and reduce the overall expense of treating pain and injury. Acupuncture and Chinese herbs, as well as the direct physiotherapies (Tui na) may also be varied for each patient and treatment, producing individualized effects that the physician can choose in response to a changing condtion of the patient. The last significant advantage of the acupuncture and Chinese herbs is that the treatments can also be expanded to stimulate improved adrenal and immune function, producing future indirect benefits for the patient. The main side effects of acupuncture, herbal and nutrient medicine, and TCM physiotherapies, is improved overall health and prevention of many common health problems and diseases, as well as future injuries that result from chronic tissue problems and degeneration. Most injuries result because of an unhealthy focal tissue pathology that leaves the patient more vulnerable to injury with mild to moderate trauma.

Patient choices in the treatment of inflammatory disease

What are the considerations when discussing this type of therapy and what are the more conservative therapies that you can try? Risk versus benefit and lowering dosage are important considerations that should be included in your discussion. Monitoring for serious harm should be adopted on a schedule. The ultimate decision on whether to take these medications always lies with the patient. Never abruptly stop corticosteroid therapies, because the body needs to respond by starting to increase the natural production of these hormones that may have been blocked by taking a synthetic analogue. Safer conservative therapies can be tried and you can see for yourself whether you are making progress with integrating these therapies. Scientific study has confirmed the efficacy of both herbal medicines and acupuncture in the role of inflammatory regulation and modulation, but the best approach is often to combine a variety of therapies to specifically address both the symptoms and underlying causes of chronic inflammatory and rheumatic conditions. This includes herbal prescription, improved diet and lifestlye, dietary supplements, physiotherapies, and acupuncture, as well as targeted stretch and exercise. The expertise and ability of the therapist administering these therapies is all important, as well as the attention of scientific study and evidence-based medicine. Herbal therapies, acupuncture, and physiotherapies are complicated subjects and there is much variation in the outcome depending on the skill of the practitioner. The choosing of the Licensed Acupuncturist if often very important, especially in more difficult diseases.

Choice of herbal medicine to treat chronic inflammatory and rheumatic conditions is also important. Many patients are swayed by internet sites that present herbal information and promote products with outlandish claims of benefit. Since the herbal industry is unregulated, commercial products should not be trusted for serious medical problems. Professional herbalists have access to products that are genuine and tested, since professional herbalists are much more demanding and educated in herbal science than the general public. These professional products may cost more than the discount products that are highly advertised, but this quality is essential to the cure. Physiotherapies may be very important in the overall treatment of inflammatory rheumatic conditions, but may be administered by therapists that have received only a few months of training. Hospitals and clinics often choose to hire the less trained physiotherapists for 'therapeutic massage'. On the other hand, a TCM physician, or Licensed Acupuncturist, may have advanced training in physiotherapies, and be able to apply this training better, due to the years of advanced education in pathophysiology received in the TCM medical school. Physical therapists are well trained but often emphasize only rehabilitative exercise rather than soft tissue therapy and passive manipulation. The TCM physician may or may not have advanced training in physiotherapy, called Tui Na in China, and this too should be a consideration when choosing an acupuncturist. Acupuncture outcome, too, is completely dependant on the skill of the practitioner. While the act of needle insertion is simple, the obtaining of a response is a subtle and complicated process that depends on both the manual skills of the acupuncturist and the attention to the responses of the individual patient to the needle manipulation.

Hopefully, you can arrive at a course of therapy that is both safe and beneficial. You may choose to try safer conservative therapies before resorting to corticosteroids, or you may be on corticosteroids and try to see if you can have success with safer conservative therapies and gradually reduce your use of these potentially harmful corticosteroids. The same is true for narcotic pain medications and NSAIDS, as well as immune suppressing drugs used to treat rheumatic pain. Certainly, when one needs to take these medications they must, but always with a consideration of adverse effects, integrating safer conservative therapies to try to reduce drug dependency and resolve the underlying causes of the pain. Putting in this effort will be worth it in the long run. Either way, I hope this handout had helped you to make these important decisions.

One more note: many patients feel that the steroid asthma inhalers and medications must be safe because of the widespread use. Clembuterol, an asthma medication similar to albuterol, is used by professional athletes and bodybuilders to promote muscle growth. This steroid inhaler has the same strong effects that other steroids have. Often, patients with chronic conditions and deteriorating health see a worsening of allergic asthma and skin conditions, and eventually are taking multiple medications that contain corticosteroids and anti-inflammatory chemicals. Eventually, your health will pay the price for this, and adverse health effects and deteriorating health can be prevented with short courses of acupuncture periodically and sound advice and prescription of herbal and nutrient medicine.