Naturopathic Care & Pain: Lessons from an Interdisciplinary Medical Practice – Part 2
Judith Ancheta, ND
As a proud member of the naturopathic profession, I am very aware of our ability to effect profound changes in our patients’ health. The patients with whom we work can confirm this. In Part 1 of this article (NDNR, July 2016), I talked about how effective management of the chronic pain patient ideally involves inter-collaborative efforts by more than 1 type of healthcare professional. I discussed both the challenges and lessons learned while working within such a collaborative team.
In this article, I will delve into specific treatment considerations in the co-management of fibromyalgia and chronic non-cancer pain patients, as well as present a clinical case as an example.
Fibromyalgia & Chronic Non-Cancer Pain Patients: Clinical Challenges
The challenge in assessing the efficacy of a given treatment is that the fibromyalgia and chronic pain population is a heterogeneous one with high healthcare resource use, direct costs, and cost-effectiveness for a given treatment.
For patients with fibromyalgia and chronic non-cancer pain, the mainstay of most family physicians’ recommendations is the use of non-steroidal anti-inflammatory drugs (NSAIDs). NSAID mechanisms are primarily driven by the interactions of the proinflammatory cytokines interleukin (IL)-1α, IL-1β, IL-6, and tumor necrosis factor-alpha (TNF-α).1,2 Elevated TNF-α concentrations are believed to initiate the cardinal signs of inflammation. My clinical observations are in agreement with Maroon et al (2010)1 that in most cases the genesis of pain is inflammatory, regardless of etiology.
Highlighted here are selected herbal and pharmacological considerations for fibromyalgia and chronic non-cancer pain patients that I have encountered in our co-managed pain population (Table 1). I have found that an understanding of these intervention-specific medical treatments is useful in helping guide naturopathic assessment and development of complementary strategies used in the co-management of the following clinical case. Management of pharmacological-herbal-nutrient interventions is a challenge in interprofessional collaborative environments. With respect to the treatment of the complex chronic pain patient, considerations include patient progress and management, and having an awareness of the therapeutic use and abuse of opioids and related issues of addiction assessment and management.
Table 1. Frequently Used Compounds for Patients with Fibromyalgia & Chronic Non-Cancer Pain – Select Considerations When Developing a Treatment Plan
|Cinnamomum camphora (Camphor)
1,8-cineole, alpha-pinene, alpha-terpineol, beta-pinene, limonene, sabinene, terpinen-4-ol, and viridiflorol
|Topical preparations are an invaluable and an underutilized treatment, with minimal-to-no adverse effects. In my practice, most of my chronic pain patients report benefit of a topical treatment like camphor, administered to intact skin during an acupuncture treatment, for its analgesic and anti-inflammatory effects. The sensory neurons of the skin contain and release a variety of neuropeptides and neurohormones, which regulate a variety of skin cells and decrease activation of adhesion molecules.3 A general dose of 10-20% semi-solid preparation, or of 1-10% camphor tincture, is recommended by Germany’s Commission E.
During the experience of pain, substance P and calcitonin gene-related protein (CGRP) are released by sensory cutaneous neurons, and released locally to induce neurogenic inflammation. These neuropeptides increase cell adhesion molecule receptors on human dermal microvascular endothelial cells.8 In an investigation examining the skin of fibromyalgia patients, using RT-PCR and immunohistochemistry, increased inflammatory cytokines IL-1β, IL-6 and TNF in 30% of patients indicated neurogenic inflammation. This may explain the positive response, in a subset of fibromyalgia and chronic pain patients, to NSAID therapy or to topical application of salves primarily containing camphor and capsaicin.
Camphor’s therapeutic value is enhanced with the application of infrared heat, as it upregulates human transient receptor potential cation channel vanilloid 3, as seen in human cell studies.4 The dermal half-life of camphor applied to the arms and posterior was found to be approximately 5.6 hours in healthy adults,4 which should be taken into consideration when counseling patients about frequency of topical application. Percutaneous absorption is of importance, as it has to be absorbed to an adequate extent and rate to achieve and maintain therapeutic levels throughout the duration of use. The cutaneous absorption (Cmax) of camphor over 8 hours reveals that plasma concentrations increase proportionate to the amount applied to the stratum corneum of the dermis.4 Practically, this may offer a way of extending the therapeutic value of in-office treatments such as acupuncture. As with all herbal treatments, caution using camphor with first application is advised, as it may cause contact eczema, although clinically I have never observed this in practice and have not observed any adverse effects from these topical applications.
|Boswellia serrata (Frankincense)
70% organic acids, 35% boswellic acid
|Acetyl-11-keto-beta-boswellic acid is 1 of the 4 major pentacyclic triterpenic acids found in the gum resin of Boswellia serrata that contribute to its analgesic effects. Acetyl-11-beta-boswellic acid is a highly specific inhibitor of 5-lipoxygenase, an enzyme for leukotriene biosynthesis.5
Based on in-vitro evidence, Boswellia can inhibit CYP P450 enzymes 1A2, 2C8, 2C9 [be careful with pain patients using ibuprofen, phenytoin, warfarin], 2C19 [be careful with patients using amitriptyline, lansoprazole, omeprazole, phenytoin], 2D6, and 3A4.5
In my practice, chronic pain patients have benefitted from Boswellia serrata containing 70% boswellic acid, 100-400 mg. The half-life of a single dose of 333 mg of Boswellia is 6 hours.5 A dose of 4200 mg/d of Boswellia serrata extract resulted in average steady tissue concentrations (ng/mL).5 Boswellia can disrupt the proinflammatory cascade, as bowellic acids inhibit the transport activity of p-glycoprotein, which may impact its absorption through the intestinal wall. Meals with a high fat content increase the concentration of boswellic acids.
Caution is advised using the herb in patients with autoimmune disease, due to its immunostimulant effects, particularly for pain patients with comorbidities including MS, SLE, and RA.5
|The combination of these 2 analgesic agents is advantageous, as they work synergistically. It is indicated for patients with moderate-to-severe pain that is not addressed by NSAIDs or opioids alone.6 Acetaminophen is known to deplete glutathione and may decrease the therapeutic effects of glutathione.7|
|This works by affecting dopamine-norepinephrine reuptake inhibition.8 In practice, a common side effect seen in the chronic pain population is appetite suppression; it also can have a notable suppressive effect on libido.|
|Augmenting the function of neurotransmitters serotonin and norepinephrine leads to stronger analgesic effects than pharmacological agents that inhibit either one or the other. This drug is indicated for neuropathic pain accompanied by tissue injury. Nerve fibers are thought to be damaged or dysfunctional, sending incorrect afferent pain signals to pain centers, resulting in changes in function at the site of the injury and areas around the injury. Common side effects include nausea, dry mouth, and constipation.9,10|
|Although TCAs inhibit reuptake of both serotonin and norepinephrine and have shown efficacy for the treatment of fibromyalgia, long-term use of these drugs is limited owing to poor tolerability.9 Major interactions are possible with 5-HTP, grapefruit, Ephedra, kava, L-tryptophan, lithium, and St John’s wort. Caution using this with Boswellia, as it inhibits CYP P450 3A4.10|
|Chronic pain patients receiving IV lidocaine to improve pain levels have noted improvements similarly discussed by Kosharskyy et al (2013)11: following lidocaine treatment, 11-point scales revealed significant reductions in pain score, pain relief interruption, mean daily duration of pain, and verbal assessment of pain, also improvements in mobility, driving, and sex life. Psychological and sociological dimensions of the pain and its relief were addressed by measurement of depression, coping ability, dependency, sleep, social life, work, and housework.
Lidocaine acts on the sodium channels in the neuronal cell membrane by reducing the flow of sodium in and out of nerves, thereby decreasing the initiation and transfer of nerve signals that are thought to play a role in the pathogenesis and maintenance of inflammatory and neuropathic pain.11
|This local anesthetic can be used in chronic pain patients to block the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential.12 In general, the progression of anesthesia is related to the diameter, myelination, and conduction velocity of affected nerve fibers.
Use of this opioid analgesic for nerve block is dependent on the area to be anesthetized, the vascularity of the tissues, the number of neuronal segments to be blocked, the depth of anesthesia and degree of muscle relaxation required, the duration of anesthesia desired, individual tolerance, and the physical condition of the patient.13,14
|This drug can significantly deplete calcium and insignificantly deplete vitamin K.15 Many anticonvulsants can decrease calcium absorption by increasing the metabolism of vitamin D, which is needed for calcium absorption.15 Hence, I like to monitor patients’ calcium and vitamin D levels, being aware of cases of hypocalcemia and osteomalacia, especially in patients taking this or other anticonvulsants for 6+ months. Gabapentin can also induce liver enzymes and increase vitamin K metabolism.15
According to one systematic review, 6 in 10 fibromyalgia patients taking gabapentin can expect to have an adverse event: 2 in 10 reported dizziness, 1 or 2 in 10 reported somnolence, 1 in 10 peripheral edema, and 1 in 10 gait disturbance, with 1 in 10 persons withdrawing because of adverse events.16 A short trial is thus recommended to assess a patient’s candidacy for determining a patient’s suitability for gabapentin.14 In this same review, benefits included a 50% reduction in pain intensity. Degree of pain relief took into consideration sleep interference, fatigue, and depression, as well as quality of function and work.16 Over half of those treated with gabapentin will not experience worthwhile pain relief.16
Theoretically, concomitant use of herbs with sedative and serotonergic properties might enhance gabapentin’s therapeutic and adverse effects. Use caution with herbs and supplements with sedative properties: L-tryptophan (which converts to 5-HTP, then to serotonin) has sedative effects that can penetrate the BBB, and is prescribed for chronic pain patients with insomnia, sleep apnea, depression, anxiety, and PMS; however, it can cause drowsiness and sedation.15 Similarly, caution is advised with concomitant use of kava in chronic pain patients, particularly if you are also considering this botanical for anxiety to enhance mood or cognition or to treat insomnia.
Gamma-aminobutyric acid analogue
|This is an analogue of the GABA neurotransmitters, an inhibitory modulator of neuronal activation of hyper-excited neurons.17 Similar to gabapentin, it can deplete calcium and vitamin K. It can also have moderate interactions with ashwagandha, skullcap, berberine, black walnut, calendula, caraway, cascara, coriander, German chamomile, Siberian ginseng, glucomannan, lavender, lemon balm, magnolia, marshmallow, melatonin, motherwort, passionflower, slippery elm, and valerian.17|
|This synthetic corticosteroid, which is injected intra-lesionally and intra-articularly, has marked anti-inflammatory action. It has been shown to moderately deplete calcium, chromium, magnesium, and vitamin D, and to insignificantly deplete zinc, selenium, and strontium.18|
|Like other SSRIs, this drug works by inhibiting the reuptake of serotonin.
It has been shown to significantly deplete calcium and potassium, moderately deplete magnesium, pyridoxine, thiamine, and zinc, and insignificantly deplete vitamins K and C.19 Be careful with nutrients that interact with CYP P450 enzymes.19
(RT-PCT = reverse transcription polymerase chain reaction; IL = interleukin; TNF = tumor necrosis factor; NSAID = non-steroidal anti-inflammatory drug; CYP = cytochrome P450; MS = multiple sclerosis; SLE = systemic lupus erythematosus; RA = rheumatoid arthritis; TCA = tricyclic antidepressant; 5-HTP = 5-hydoxytryptophan; RCT = randomized controlled trial; BBB = blood-brain barrier; SSRI = selective serotonin reuptake inhibitor)
Co-managed Case Study
At the time of assessment, female patient BA* was 40 years of age and of Scottish descent; she was diagnosed with fibromyalgia 4 years prior to her naturopathic medical evaluation. The patient identified 14 of the 18 tender points characteristic of fibromyalgia (suboccipital muscle insertions at occiput, lower cervical paraspinals, trapezius at midpoint of the upper border, supraspinatus at its origin above medial scapular spine, 2 cm distal to lateral epicondyle in forearm, upper outer quadrant of buttock, knee just proximal to the medial joint line) (Figure 1). She reported widespread muscle pain, myalgias, fatigue, poor sleep, severe premenstrual syndrome, constipation, gastroesophageal reflux, reduced libido, and difficulty concentrating following an incomplete recovery after 2 successive motor vehicle accidents (MVA), the first being a head-on collision, the second accident being T-boned by another driver; the 2 MVAs occurred 3 years apart. She cited the second accident as marking the onset of her fibromyalgia and chronic pain. She had been receiving interventional treatments from our medical pain specialists, primarily consisting of intravenous (IV) bupivacaine once every 3 months, with focal injections of lidocaine and daily medications consisting of oxycodone/acetaminophen, medical marijuana, and bupropion to manage the musculoskeletal pain. Prior to her first MVA, she had had no significant medical history and no hospitalizations. Post-accident, she was left with no choice but to leave her position in the healthcare sector, requiring physical help with childrearing from supportive family members.
Healthcare Goals & Treatment
At the time of presentation to our office, this patient identified a long list of health concerns. She also identified her wish to focus on improving her diet to help facilitate overall health, given that her medical interventional treatments had helped to drastically improve her baseline pain levels. The patient expressed interest in focusing on health maintenance and improvement, though at the time of presentation in-office, she was also prepared to adjust to a life of lowered daily functioning, with expressed resignation and acceptance that the chronic pain she was experiencing might be life-long.
Healthcare goals we agreed to initially address included the following:
- Alleviate muscular pain – notably of the upper neck and traps, right sacrum, and hip.
- Improve digestive health. She would like to learn to read food labels and eat better, including reducing her sugar consumption. We are working on addressing nutrient deficiencies and the ability to assimilate food consumed.
The success of this patient was largely due to her high level of compliance following in-office recommendations for timing of meals, and incorporation of medicinal foods Since her first encounter, we diligently addressed nutrient deficiencies through food and basic nutrient supplementation. Her primary-care physician played a large role in her improvement, working with us to coordinate care of this patient and identify laboratory investigations covered under Ontario Health Insurance Plan (OHIP); selections were made in light of the patient’s limited resources while on work disability. Her polypharmaceutical use had greatly reduced her appetite; this was an additional challenge to overcome, given that she needed nutrient-dense foods and supplementation to gain her strength back and recover.
Her naturopathic care plan included weekly acupuncture treatments, primarily to address her musculoskeletal pain, to support her digestive health, and as a key component in our strategies to help with stress reduction. Given her low serum vitamin B12, she was provided with intramuscular (IM) injections of methylcobalamin and hydroxocobalamin injections (1000 µg/mL), alternating between her right and left posterior deltoid muscles. [These were administered prior to the proclamation for Ontario Naturopathic Doctors which now requires Ontario NDs wishing to administer IM injections to update their education.] She also received a commercial complex homeopathic preparation containing Harpagophytum procumbens, Arnica montana, Bryonia, Calcium phosphoricum, and Acidum silicum. She reported an improvement in muscular hypertonicity, from 9/10 (10 being the worst) to a 5/10, and improved mental clarity despite ongoing relationship challenges that worsened her pain levels. Although she was scheduled to receive a lidocaine infusion, she reported (in the first month of us working together last year) that she was no longer “counting down the days” until her next medical treatment; this was due to the now-manageable pain levels on the 1 oxycodone/acetaminophen and medical prescription cannabinoids.
Exercise prescriptions for this patient were designed to reduce pain by increasing strength, aerobic conditioning, flexibility, and balance, as typically recommended for this population of people. Several low-impact exercise options were presented for the patient’s consideration, including Aquafit classes, reclined stationary bike, elliptical, and Nordic pole-walking. An emphasis was placed on the benefits of exercise, including improved muscular blood flow, decreased susceptibility to muscular microtrauma, and an improvement in sleep. The patient was able to confirm how a lack of physical activity perpetuated less physical activity, depressed moods, and more pain.
The initial exercise prescription was to begin walking 5 minutes the first day, and increase this by 1 minute per day. This patient was able to implement the suggested strategy and achieve walking a total of 60 minutes per day, 3 to 4 times per week, within her pain tolerance levels. The goal we discussed was to work towards being able to incorporate a slow jog, which the patient reported she was able to do prior to her MVAs. At the end of 4 months, this patient was able to increase her exercise tolerance, from being sedentary to walking her dog for 1 km, within the first 4 months of our work with one another.
In addition to the naturopathic care being received, to further aid her acquisition of knowledge regarding her condition and to enhance the implementation of positive dietary and lifestyle habits discussed in-office, she was recommended to concurrently attend the Fibromyalgia and Chronic Pain Conditions program at the clinic; this consists of two 40-minute interactive lectures over 6 weeks. The lecture series provided by various members of the clinic’s healthcare team focuses on providing these patients with information about how the various specialties (medicine, naturopathic medicine, chiropractic medicine, psychotherapy) may contribute to quality patient care and management (Table 2). To ensure participant involvement and interaction, the classes are limited to small class participant-to-provider ratios per session.
Table 2. Fibromyalgia & Chronic Pain Conditions – Naturopathic Medicine Lecture Series
|Part 1: Implementing Easy Nutritional Strategies
· Naturopathic medical care and your health
· How to turn routine meals into nutrient-dense meals
|Part 2: Focusing on Nutritious Medicinal Foods and Lifestyle Strategies
· Learn about different super foods and their nutritional content
· How modifying dietary intake can improve your chronic pain levels and health
|Part 3: Spotlight on Healing Herbs
· A holistic approach to fibromyalgia and chronic pain management, with the help of household herbs
|Part 4: Ancient Wisdom and Modern Practices – Traditional Chinese Medicine and Acupuncture
· Naturopathic medical care, acupuncture, and your health
· How acupuncture works
· Acupuncture treatment demonstration
· Benefits of acupuncture treatments
Patient’s Progress Over Time
In the first month, the patient’s full medical history was reviewed, with overt nutrient deficiencies identified and corrected. Given the number of medications this patient was on, recommendations were strongly based first on modifying dietary intake and lifestyle; this was followed by supplementation, homeopathic medicine, acupuncture treatments, and the use of herbal products.
The patient began implementing dietary strategies for a varied, nutrient-dense diet with a strong focus on the Paleo diet, to combat her loss of appetite. Dietary considerations had to be palatable for the whole family, considering this patient’s reliance on help from family members preparing healthful foods on the days her pain levels were elevated. She was instructed to increase the consumption of quality protein by choosing organic, free-range eggs, chicken, pastured beef, fresh wild-caught salmon and halibut, and to purchase the best-quality foods that she could. Her motivation was stimulated between in-office treatments, and she regained her appetite, which helped to further facilitate her energy.
After receiving acupuncture treatments, she reported that her generalized pain with interventional treatments was an 8/10 (10 being the worst). On commencing her naturopathic treatment, this decreased to a 4/10. Improvements in this patient’s generalized myalgia and chronic pain further helped decrease her reliance on topiramate for her headache pain. Following a discussion with her neurologist, she was able to reduce her use of topiramate; she was also able to reduce her dose of bupropion by half following discussions with her family doctor and psychiatrist.
Most notably, the changes in dietary intake and lifestyle led to improvements in this patient’s symptoms of severe dysmenorrhea and emotional lability. As she shared, both in-office and in-lecture, the care we were providing her was helping reduce her pain levels, which in turn improved her emotional and physical well-being, which in turn helped her improve her relationship with her spouse, family members, and children. She reported that she was not easily “flying off the handle” as she had previously, and this resulted in a perceived improvement in her quality of life.
The reduction of bupropion helped her regain her libido. Months previous to receiving naturopathic care, she had not even considered it a “problem” until she was experiencing improved health. Where bupropion had once helped her manage her fibromyalgia and depressed moods, she now reported no longer needing it, particularly as it left her with a flat affect (she otherwise described herself as being charismatic and vibrant).
In the second month of treatment, the reduction of medications further helped the patient taper her use of proton-pump inhibitors, given the improvements in gastroesophageal reflux and digestive complaints. Although previously tending toward a constipated state, she now reported an improvement in regular daily bowel movements. The patient also reported an improvement in the dark circles under her eyes as she minimized refined sugar, artificial additives, and preservatives in take-out foods. She had previously become reliant on commercially prepared foods on the days she said were the most difficult to get out of bed due to the widespread pain.
Strategies were provided in-office and in-lecture to help her during these particularly low-energy days that were marked with increased reports of pain. These strategies included, but weren’t limited to: 1) preparing healthful, nourishing meals that were frozen in advance for the upcoming weeks and taken out for consumption on the days she was not feeling at her best; 2) portioning home-cooked meals in advance for the week when she had increased energy (eg, making snacks of veggies and fruits more readily available when she was hungry, thereby reducing her need to consume commercially prepared snack foods); and 3) on the days she felt particularly sore, using common household tools such as scissors to help cut up veggies (as opposed to a knife) to minimize the discomfort felt with the repetitive use of the synovial joints between the distal end of her radius and the carpal bones.
By the third month of treatment, this patient reported experiencing more extended periods of pain relief between her interventional treatments. Where she once found she was “counting down the days” before she could receive IV bupivacaine, she was now reporting significantly less discomfort come time for her IV treatments. She also noted that the weekly acupuncture treatments were reducing her persistent head pain. In addition to experiencing fewer episodes of head pain, she also experienced a reduction of her photosensitivity. As for her other interventional treatments, the patient reported requiring fewer focal injections of lidocaine that were alternated with triamcinolone injections for effective pain management.
By the fourth month, the patient felt significantly improved energy levels with the naturopathic care she had been receiving, and wanted to initiate discussion of completely discontinuing her bupropion with her psychiatrist. She also reported that she had reduced the amount of cannabinoid used, which prior to receiving naturopathic care had helped her achieve more manageable pain levels.
This patient continues to receive ongoing interdisciplinary care for the management of her chronic pain, although she would now say that her goals of treatment have changed, being geared now more toward maintenance and improvement of health. This case is an example of how a complex, chronic pain patient, who ordinarily might only receive interventional medical treatments in-office, can achieve successful outcomes under the concurrent care of a community naturopathic doctor practicing within the context of an inter-collaborative patient-care management team.
Implications for Practice & Educational Initiatives
In my opinion, professional and public acknowledgement and awareness will increase the better we become at articulating our profession-specific capabilities and scope of practice. Programs which support educational and grassroots projects and clarify profession-specific language are necessary. It is important to reinforce that our intent as a profession is to contribute to improved patient outcomes rather than being antagonistic towards other healthcare professionals. Raising awareness of our profession starts at the clinics in which we practice. Once we become proficient at this, it is hoped that the incorporation of naturopathic care within interdisciplinary care models will occur more readily for the management of all patients, not only for those with chronic pain.
Naturopathic doctors would benefit from participating in an interprofessional pain curriculum and modeling of interprofessional roles within the context of pain management in order to increase complex knowledge and appreciation of professions other than one’s own, similar to previous endeavors conducted by Reeves et al (2009).20 Continued endeavors to recognize and foster respect of roles, responsibilities, and competence of a multitude of service providers in relation to the naturopathic profession, as well as knowing when, where, and how to involve these other providers, will, in my opinion, help further the profession as a whole and guide how we coordinate care among healthcare team members and with the general public, educating them in the process about the healthcare solutions available to them.
The development of a succinct, validated pain scale could be utilized by naturopathic doctors in community family practice settings. Collection of this data would provide valuable information about the contribution of naturopathic care where pain management is concerned. An important consideration was highlighted by Price et al (2013),21 that is that a visual analogue scale (VAS) for the assessment of pain management is not equivalent to an 11-point numerical rating scale (NRS). VAS shows high test-retest reliability and repeatability, internally consistent measures of clinical and experimental pain, sensitivity to variables that increase or decrease pain, capacity to measure multiple dimensions of pain, strong association with measures of pain-related activity in the human brain and – in the case of mechanical or electronic VAS – must be simple and easy to use, especially given that some degree of cognitive impairment exists in the chronic pain population.21 In contrast, it has been suggested that the NRS repeatedly evokes artificially high ratings at the lower end of the scale (no pain, moderate, and worst possible pain).21
The position of the Canadian Rheumatology Association is that use of the 7-point Likert scale is best.22 A validated pain scale adapted for naturopathic use can in turn be used to help disseminate the breadth of rich information and care that naturopathic doctors impart to patients to improve health and its foundations. An additional resource to consider is the use of the Revised Fibromyalgia Impact Questionnaire Revised.23 The collection of data from the use of such a questionnaire would help capture naturopathic outcomes of reduced bodily pain and improved physical, social, and emotional functioning. As a result, this would further help the naturopathic profession create opportunities for research into the continued development, implementation, and support of coordinated educational multidisciplinary team approaches for the management of chronic pain patients. The philosophy of naturopathic care lends itself naturally to helping improve chronic pain patients’ health, given our creative utilization of modalities and the time we are able to spend with patients over a series of visits.
Naturopathic care can help with difficult-to-treat pain, enhance patient outcomes, minimize loss of work, decrease medical leave and costs, and improve quality of life for patients living with chronic pain and fibromyalgia. It is hoped that future educational initiatives will utilize the lessons learned from integrated curricula initiatives,24-26 fund teaching strategies, and create opportunities for naturopathic doctors to be represented alongside our conventional health science faculties.
As a naturopathic doctor practicing north of the General Toronto Area, I have observed increasing recognition of our contributions in multidisciplinary care models of complex patients with chronic pain. While various methods have been proposed to assess quality of pain management, there does not seem to be 1 pain scale that is used to communicate easily trackable outcomes across interdisciplinary settings. The development, implementation, and support of coordinated educational programs in pain management, where naturopathic doctors are recognized as a universally valued team member, have yet to occur. The opportunity to hear each profession’s language, interests, goals, content priorities, and learning environment preferences will help naturopathic doctors share their knowledge and have it reciprocated for true interdisciplinary, inter-collaborative care for complex cases.
One obstacle to this advancement is that using several different interventions for the same clinical condition can be challenging in the context of co-managed care in the community setting. One way that naturopathic doctors can overcome this barrier to care is by articulating our roles, particularly where there is overlap in scopes of practices, and to reinforce our intent to contribute to the betterment of patient care and outcomes. It is hoped that, as a profession, we will come up with standardized ways to disseminate information derived from the use of our naturopathic modalities, and to use information from the collective profession to track the outcomes achieved with patients; this will help generate the data and case reports needed to help our healthcare counterparts more readily understand our contributions to complex patient care co-management.
*The identifying details of this patient were changed to protect patient confidentiality.
Judith Ancheta, ND, is a graduate of McMaster University in Hamilton, Ontario, and the Canadian College of Naturopathic Medicine in Toronto, Ontario. She has been in practice since 2011 and provides compassionate, patient-centered healthcare within an interdisciplinary medical team model. The naturopathic care provided often means that patients can minimize the amount of pain medications needed and frequency of interventional treatments for pain, based on the recommendations of their interventional medical physicians at the Wilderman Medical Clinic. She regularly lectures in the clinic’s Fibromyalgia and Chronic Pain Program, to help patients with their pain and to improve their quality of life.
- Maroon JC, Bost JW, Maroon A. Natural anti-inflammatory agents for pain relief. Surg Neurol Int. 2010;1:80.
- Wallace DJ. Is there a role for cytokine based therapies in fibromyalgia. Curr Pharm Des. 2006;12(1):17-22.
- Farage MA, Miller KW, Maibach HI, eds. Textbook of Aging Skin. Berlin, Germany: Springer Berlin Heidelberg; 2010:791-792.
- Therapeutic Research Center. Camphor Monograph. Natural Medicines Professional Database. Available at: https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=709#effectiveness. Accessed March 9, 2016.
- Therapeutic Research Center. Boswellia Monograph. Natural Medicines Professional Database. Available at: https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=709#effectiveness. Accessed March 9, 2016.
- Gatti A, Sabato E, Di Paolo AR, et al. Oxycodone/paracetamol: a low-dose synergic combination useful in different types of pain. Clin Drug Investig. 2010;30 Suppl 2:3-14.
- Therapeutic Research Center. Depletion Checker: Acetaminophen, Oxycodone (Percocet). Natural Medicines Professional Database. Available at: https://naturalmedicines.therapeuticresearch.com/#. Accessed April 14, 2016.
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- Mease PJ. Further strategies for treating fibromyalgia: the role of serotonin and norepinephrine reuptake inhibitors. American J Med. 2009;122(12 Suppl):S44-S55.
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- Lambrechts M, O’Brien MJ, Savoie FH, et al. Liposomal extended-release bupivacaine for postsurgical analgesia. Patient Prefer Adherence. 2013;7:885-890.
- Bupivacane Hydrochloride Injection USP. Drugs.com Web site.https://www.drugs.com/pro/bupivacaine.html. Accessed April 14, 2016.
- Gadsden J, Long WJ. Time to Analgesia Onset and Pharmacokinetics After Separate and Combined Administration of Liposome Bupivacaine and Bupivacaine HCl: Considerations for Clinicians. Open Orthop J. 2016;10:94-104.
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- Moore RA, Wiffen PJ, Derry S, et al. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2014;(4):CD0007938.
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- Reeves S, Zwarenstein M, Goldman J, et al. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2008;(1):CD002213.
- Price DD, Staud R, Robinson ME. How should we use the visual analogue scale (VAS) in rehabilitation outcomes? II: Visual analogue scales as ratio scales: an alternative to the view of Kersten et al. J Rehabil Med. 2013;44(9):800-801.
- Canadian Rheumatology Association. Position Paper on Fibromyalgia. Updated September 2015. CRA Web site. https://rheum.ca/images/documents/CRA_Position_Paper_on_Fibromyalgia_(updated_Sep_2015).pdf. Accessed March 20, 2016.
- Bennett RM, Friend R, Jones KD, et al. The Revised Fibromyalgia Impact Questionnaire (FIQR): validation and psychometric properties. Arthritis Res Ther. 2009;11(4):R120.
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