Techniques in Regional Anesthesia and Pain Management (2008) 12, 99-101

Integrating complementary and alternative treatments

into an anesthesia-oriented chronic pain practice
Complementary and alternative medicine modalities
(CAM) have often been negated as extraneous or even
framed as suspect by those in the biomedical field. Yet,
there are good reasons to be aware of the CAM modalities
that our patients practice. Learning more about CAM also
offers us an opportunity to expand treatment options for
those patients who are not fully responding to our approaches. This issue of Techniques in Regional Anesthesia
and Pain Management includes articles related to the use of
CAM, written by CAM practitioners.
When Oscar de Leon asked me to be editor for an issue on
Complementary and Alternative Treatments for Chronic Pain,
I initially declined. I am a Psychiatrist; my first thought was
Im no expert on such things; I read the experts, I go to hear
them speak. On further reflection, I realized I am an expert in
our efforts to integrate Alternative and Complementary Modalities (CAM) for our patients at the Center for Pain Medicine
in Burlington, VT, and can share our experience. Our center
consists of five Anesthesiologists, and two to three Fellows
from Anesthesia. We now have an Advanced Practice Nurse
working in tandem with me.
What is Complementary and Alternative Medicine? One
answer is any treatment I didnt learn about in my medical
training. A more formal definition, presented by the National Center for Complementary and Alternative Medicine
(NCCAM) found on their Web site (http://nccam.nih.gov)
is: a group of diverse medical and health care systems,
practices, and products that are not presently considered to
be part of conventional medicine. Complementary modalities are used in conjunction with allopathic medicine,
whereas alternative modalities are used in place of conventional medicine.
When considering CAM, a good question to ask is:
alternative and complementary to what? Many treatment
paradigms and methods have been around since long before
our Western, allopathic model developed. Recent empirical
evidence suggests that many of these CAM methods have
endured because they have genuine effects.1,2

The author thanks Cheryl Laskowski, APRN, for her helpful insights in
helping him write this editorial.

1084-208X/$ -see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.trap.2008.01.004

Why even be concerned about CAM? For one, many of our

patients are involved with them. In one study of CAM use
between the years 1997 and 2002, it was found that nearly 1 in
3 people in the United States, about 72 million individuals, had
used CAM in the past year.3 One of the fastest growing fields
of CAM, herbal medicine, was used by nearly 19% of US
adults between the years of 1997 and 2002. Nearly 50% of
patients who use CAM first seek information related to it from
their primary care physician.4 Individuals with chronic health
problems, including anxiety, back problems, chronic pain, and
urinary tract disorders, are the most frequent users of CAM.5
Given that many of our patients present with one or more of
these concerns, it is likely that many of the patients with whom
we work are using CAM modalities. Subsequently, it is important to be familiar with how CAM treatments interact with
ours. Omega-three fatty acids and garlic may affect platelets
and ultimately impact on several anesthesia interventions. Chiropractors and body workers may do manipulations that are
poorly timed with nerve blocks.
Why be familiar with the concepts and practitioners of
CAM? Our patients see us as their experts and as advocates
for pain management. There may come times when our
allopathic treatments offer little relief to exhausted patients.
Telling these patients that there is nothing left to do or
that they are at treatment end is demoralizing, and leaves
patients hopeless and despairing. Directing patients to other
modalities and models demonstrates our interest and concern.
How can we learn something of the other options, and
make such suggestions with some sense of comfort? I suggest that we bear this responsibility in the doctor/patient
relationship. Yet, we hardly want to send our patient to a
practitioner whose treatments are a total mystery to us. Just
as in referring patients to health care Web sites, when
suggesting CAM modalities and/or practitioners, we have
an obligation to become familiar with indications and contraindications of CAM resources that are commonly used by
our patients.6 To better integrate CAM modalities, we can
share our experience with learning of and using the CAM
resources in our community.
At the Center for Pain Medicine we have held monthly

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Techniques in Regional Anesthesia and Pain Management, Vol 12, No 2, April 2008

lunch meetings, Interdisciplinary Rounds, to discuss patients; initially focused on the Anesthesia and Psychiatry
perspectives, over time this forum began to evolve into
inviting different CAM providers to come in and teach us
about their treatment paradigms, types of patients they may
have the best results with, and resources that reflect empirical data on their methods as well as on their results. This
forum has enabled our practitioners to get a clearer sense of
the philosophy and practice style of several local CAM
practitioners. This also served to develop relationships with
such practitioners and demystified what happens with their
CAM patients who are also served in our clinic. In fact, we
began to see more referrals to and from the community
CAM providers. Another benefit of developing these relationships is the opportunity for students and Residents rotating through the Pain Clinic to do field trips, spending
afternoons in the practices of these CAM providers.
Many students are eager to get exposure to CAM, and
express a desire to integrate CAM into patient care. I have
seen Residents meet with Naturopaths, skeptical that there
will be anything to offer, only to have the student be astounded by the Naturopaths grasp of biochemistry and
metabolism, far eclipsing the understanding of most allopathic providers. Conversely, I have also seen Residents
return from CAM providers with the sense that they would
not subject their patients to a particular treatment.
Another process in parallel with our Interdisciplinary
Rounds is the development of an Integrating CAM into
Organized Medicine work group which has been meeting
monthly in the evening for the past 2 years. Integrative
medicine combines allopathic and CAM modalities while
seeking empirical evidence of treatment safety and efficacy.7
There are a rich number of CAM providers in a community such as Burlington, although they do not often interact
with the allopathic providers, and sometimes not much with
each other. In our monthly group, providers educate each
other on their discipline. We have presented case histories
on patients from the Pain Clinic where each discipline
describes how they might assess and treat the patient; more
than once the image of the blind men describing the elephant has emerged. We struggle with many issues, including how to advocate for coverage from insurance companies
and government entities to integrate CAM into allopathic
treatment modalities. We also recognize that many CAM
providers are leery of being strictly regulated and subsumed
under the biomedical model.
Previously in this journal, I have described some concepts
and treatments for patients with chronic pain from a psychiatric
perspective that may be considered complementary or alternative from the Anesthesiologists perspective.8 In the current
issue, we present some of the CAM models from providers in
our community, experts to whom I turn to provide more
comprehensive treatment for many of my patients.
We include one particular aspect of Physical Therapy
(PT). Interestingly, I had absolutely no teaching on PT
throughout my medical training, and initially thought all PT
was the same. Through my work with physical therapists in

the community, I have come to appreciate the unique place

for Postural Restructuring, obtaining results from more than
one patient who initially said: I had PT; all it did was make
me worse.
We include an article from a Naturopathic Physician.
Patients presenting with concerns such as fibromyalgia,
chronic fatigue syndrome, and irritable bowel syndrome
have usually seen many providers with little success. Their
providers may be desperate for help, yet traditional Western
Medicine often has limited success in treating such chronic
diseases. I have found that the Naturopathic providers can
provide treatments beyond my training; I have learned about
such topics as Vitamin D, oxytocin, omega-three fatty acids,
and Wilsons Temperature Syndrome, which have had a
great impact on many of the patients I follow.
We offer an article on Acupuncture. Many of our patients
have heard about acupuncture and ask for our opinion on
using this treatment. Clarification of concepts such as chi
and meridians may not roll easily off our tongue. Research done at the University of Vermont concerning the
metabolic response of fascia to acupuncture may be a paradigm we are more comfortable in invoking.
We offer two articles on Psychological treatments, with
which some Pain Practitioners may not be familiar. Biofeedback has applications when psychophysiologic arousal exacerbates conditions such as migraine, TMJ, back pain, and
IBS. Monitoring has progressed from EMG to heart-rate
variability, which may be useful for other indications in
stress-management. Another focus, Mindfulness Meditation, is an approach that may be helpful for patients who
find that CognitiveBehavioral and Psychodynamic Psychotherapies are not helpful.
We have included an article on incorporating Compounding Pharmacy into our tool kit of pain management.
Although this may not have the same background of CAM
as other modalities, it is an area of Pharmacology I had no
exposure to in my medical training. I have found compounding pharmacy invaluable in allowing for additional
treatment options, such as MgCl creams for myofacial pain,
incorporating ketamine, amitripyline, ketoprofen, neurontin,
and other agents in a topical form for neuropathic pain. Ive
learned that I dont have to have all of the information; my
local compounding pharmacist educates me on options that
are available and emerge from his own education. For patients focused on opioids but for whom they may be inappropriate, ineffective, or intolerable, having a range of options helps me feel less helpless. For patients with Crohns
disease and extensive resection who may have absorption
difficulties, sublingual preparations may be helpful.
There are other CAM modalities in our community, such
as Homeopathy, Spiritual Direction, Reiki, and other energy
therapies, that we have not described here. One may learn
more about CAM through journals that endeavor to present
CAM in a more evidenced-bases manner, such as the Journal of Alternative and Complementary Medicine, Alternative Therapies in Health and Medicine, and Explore. There
are also an increasing number of conferences on integrating

Erickson

Anesthesia-Oriented Chronic Pain Practice

CAM and allopathic medicine. There are many organizations focused on functional medicine and holistic medicine.
One does not need to become an expert in CAM to make
a difference in the treatment of our patients; rather, we can
become familiar with our local CAM community resources.
Weve found that our patients expect this, it enhances our
understanding of chronic pain, and sometimes some patients
(as well as providers) can benefit.
Brian Erickson, MD
Guest Editor
References
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and alternative medicine by US adults: 1997-2002. Altern Ther Health
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4. Eisenberg D, Kessler R, Van Rompay M, et al: Perceptions about
complementary therapies relative to conventional therapies among
adults who use both. Ann Intern Med 135:344-351, 2001
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study. J Am Med Assoc 279:1548-1553, 1998
6. Cattell E: Nurse practitioners role in complementary and alternative
medicine: active or passive? Nurs Forum 34:14-23, 1999
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nccam.nih.gov/health/whatiscam/, 2007
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