How patients feel sets the framework for caring for patients who are experiencing pain... “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel,” noted Maya Angelou (Goodreads, 2019, para 1). How patients feel sets the framework for caring for patients who are experiencing pain, whether acute or chronic in nature. While pain may not be eliminated, how the patient reacts to the experience and interventions employed to reduce or alleviate the pain will be remembered. These interventions often include providing the patient with additional tools for coping with pain, other than pharmacological approaches. This may include integrative or complementary and alternative methods, both of which can be defined as a group of diverse medical and healthcare systems, practices, and products that are not presently considered as part of conventional medicine (Tick, 2014).

In this article, I will review the clinical relevance of pain and pain management; briefly describe the history of non-allopathic medicine; discuss five domains of non-allopathic interventions and related negative aspects; emphasize the multimodal approach; and share implications for nurses.

Clinical Relevance

The International Association for the Study of Pain (IASP) is an organization of scientists, clinicians, healthcare providers, and policymakers focused on the study of pain and the translation of knowledge into improved pain relief worldwide. This organization defines pain as, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (IASP Pain Terminology, 2017, para 3). Pain can be further classified into various types:

• acute pain, lasting up to seven days in duration (e.g., procedural pain);
• acute exacerbation of a recurring painful condition which occurs over any duration of time (e.g., migraine headache);
• chronic pain, which is persistent pain lasting longer than the expected time of healing (e.g., low back pain); and
• cancer pain which may be caused by potentially life-threatening conditions (American Society for Pain Management Nursing [ASPMN], 2010).

Though pain is subjective, it is experienced by all, including young and old, rich and poor, men and women, and members of every ethnic group.

In a 2011 report published by the Institute of Medicine (IOM) it was noted that over 100 million American adults are affected by chronic pain. This is more than the combination of those affected with heart disease, cancer, and diabetes (IOM, 2011). The report also estimated that the United States (US) spends up to $635 billion annually in medical treatment and lost productivity due to chronic pain.

Pain was identified as both a national and a public health challenge requiring a cultural transformation... The report (IOM, 2011) described disparities in pain treatment related to age, gender, ethnicity, and socioeconomic class. Pain was identified as both a national and a public health challenge requiring a cultural transformation to better prevent, assess, treat, and understand pain of all types. The IOM provided a blueprint for change, noting a key area as care of individuals with pain. The report recommended assistance with self-management, as well as a comprehensive treatment approach inclusive of complementary and alternative therapies.

Negative consequences on physiological functioning due to inadequate acute-pain management affect essentially every system in the body, yielding systemic malfunctioning (Gan, 2017; Glowacki, 2015). A link exists between poorly controlled acute pain, the development of chronic pain, and the occurrence of psychological conditions, such as depression and anxiety (Arteta, Cobos, Hu, Jordan, & Howard, 2016; Boakye, et al., 2016; Zhuo, 2016). Additionally, researchers have found that patients with underlying pain had healthcare usage greater than individuals without pain for chronic, acute and symptomatic/ill-defined conditions (Duenas, Ojeda, Salaar, Mico, & Failde, 2016; Stockbridge, Suzuki, & Pagan, 2015). A similar finding was established in relation to functional limitations, with those individuals experiencing pain having a higher rate of functional limitation than those without pain, while developing other health risks, such as obesity and inactivity (Duenas, et al., 2016).

Numerous barriers to adequate pain management are described in the literature.Numerous barriers to adequate pain management are described in the literature. Frequent barriers are regulatory restrictions for opioid prescribing; reluctance of providers to prescribe appropriate medications due to limited knowledge or fear of regulatory review and penalties from governmental agencies; adverse effects of medications; and hesitancy of patients to utilize medications, especially opioids for pain control (IOM, 2011; Martin, Laderman, Hyatt, & Krueger, 2016; National Quality Forum [NQF], 2009). A timeline of the landscape of opioid analgesics is provided in Table 1.

Table 1. Timeline of Landscape of Opioid Analgesics

(Adapted from CNN Editorial Research, 2020; Jones, et al., 2018)

Conditions associated with pain were the number one reason adults reported as the reason for using CAM therapiesAccording to the 2012 National Health Interview Survey, 59 million Americans used some form of integrative or complementary and alternative medicine (CAM) (National Center for Complementary and Integrative Health [NCCIH], 2016). This accounted for $30.2 billion spent out-of-for CAM therapies (NCCIH, 2016). Conditions associated with pain were the number one reason adults reported as the reason for using CAM therapies (Hart, 2008). The 2017 National Health Interview Survey (NHIS) found that 14.3% of adults practiced yoga and 14.2% had practiced meditation. Use of these CAM practices had increased significantly since the previous (2012) NHIS survey (NCCIH, 2018b).

Depression and anxiety are highly prevalent in patients with pain...Depression and anxiety are highly prevalent in patients with pain; and the combination of these leads to reduced quality of life, major societal costs, and increased numbers of death by suicide (Burke, Mathias, & Denson, 2015; Gerrits, van Marwijk, van Oppen, van der Horst, & Penninx, 2015). Depression and anxiety are associated with reduced psychosocial functioning resulting inadequate coping strategies, which may produce increased pain ratings over time (Gerrits et al., 2015).

Neuroimaging has changed the concept of pain from a disease affecting mainly the somatosensory system, to one in which emotional, cognitive, and modulatory areas of the brain are affected, in addition to degenerative processes (Borsook, Sava, & Becerra, 2010). The effects of pain on emotions (e.g., depression, anxiety) are potentially explained by the common anatomical brain network shared by these disorders (Dunne, 2011). All of the above factors can contribute to the development and maintenance of pain symptoms and co-morbid features, including alterations in anxiety, depression, and other cognitive functions (Borsook et al., 2010).

Non-allopathic approaches have been found useful for acute, chronic, and malignant pain. Nurses are the frontline resource for these patients. As such, they frequently must advocate for effective interventions to address patient needs. Non-allopathic approaches have been found useful for acute, chronic, and malignant pain. A sound knowledge of all available approaches, including non-allopathic interventions, for pain control, permits nurses to provide a holistic approach for patients who require pain management.

Historical Overview of Non-Allopathic Medicine

Essentially, non-allopathic medicine refers to everything outside of conventional medicine Non-allopathic medicine is a group of diverse medical and healthcare systems, practices, and products that are not presently considered part of conventional medicine (NCCIH, 2018a). Essentially, non-allopathic medicine refers to everything outside of conventional medicine (Tick, 2014). Non-allopathic medicine can be further described as complementary and alternative medicine with complementary medicine being used with conventional medicine versus alternative medicine being used instead of conventional medicine (NCCIH, 2018a). Integrative medicine is the combination of all available and appropriate strategies and approaches combined to benefit the patient (Tick, 2014). Integrative medicine focuses on an interdisciplinary approach through the development of a partnership between the patient and the healthcare team to achieve optimal health and healing.

Non-allopathic medicine is thousands of years old and has roots in the following three primary areas (USDHHS, 2002):

• Traditional Chinese medicine, which has focused on restoring harmony through the use of herbals, acupuncture, diet, massage, and exercise;
• Ayurvedic medicine from India, which has focused on prevention of illness through incorporating herbals, yoga, meditation, diet, and lifestyle changes; and
• Native American medicine, which has focused on treating the entire person to restore balance in every aspect of one’s life through healing rituals and ceremonies as well as herbals.

Conventional treatments frequently have limited efficacy for chronic diseases. In the 21^st century, an estimated 59 million Americans use some form of non-allopathic medicine which accounts for the ‘out of pocket’ spending by healthcare consumers previously noted (NCCAH, 2016). The most commonly used non-allopathic modalities are: natural products (17.7%); deep breathing (10.9%); yoga, tai chi, or qi gong (10.1%); chiropractic or osteopathic manipulation (8.4%); meditation (8.0%); massage (6.9%); special diets (3.0%); homeopathy (2.2%); progressive relaxation (2.1%); and guided imagery (1.7%) (NCCAH, 2016). Unfortunately, only about 42% of all adults and only 33% of adults 50 years and older disclose non-allopathic medicine use to their healthcare provider (USDHHS, 2011). This lack of disclosure can lead to drug-herbal interactions as well as misinformation for patients.

Domains of Non-Allopathic Medicine

Non-allopathic medicine can be divided into the following five domains:

• Alternative medical systems, which involve complete systems of theory and practice that have evolved independent of and often prior to conventional biomedical approaches;
• Mind-body interventions, which encompass techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms;
• Biologically based treatments, including natural and biologically based practice, products, and interventions (e.g., supplements, dietary changes);
• Manipulative and body-based methods, including approaches based on manipulation and/or movement of the body; and
• Energy therapies, which focus either on energy fields originating within the body (biofields) or those from other sources exterior to the body (IOM, 2005).

Examples of interventions associated with each domain are provided in Table 2.

Table 2. Examples of Non-Allopathic Interventions by Domain

(Adapted from the NCCAH, 2019)

I will use these domains to discuss the application of selected, non-allopathic interventions to pain management for acute, chronic, and malignant pain. While there are numerous complementary and alternative approaches in the literature, the non-allopathic interventions selected for this article have a substantial body of evidence, such as systematic reviews, randomized controlled trials, quantitative and also qualitative studies associated with the intervention.

Alternative Medical Systems
Acupuncture fits into the alternative medical systems category as it is an approach utilized in traditional Chinese medicine (Tick, 2014). Acupuncture entails the insertion of needles at specific points along energy (chi) pathways called meridians to restore balance thus encouraging healing (Cho et al., 2015). Acupuncture is thought to stimulate the secretion of endorphins, serotonin, and noradrenalin in the central nervous system while also affecting blood vessels due to release of vasodilators (e.g., histamine; Khatta, 2007). Acupuncture may also control pain via the Gate Control Theory, which asserts that a sensory stimulant can be suppressed by another stimulant within the neural system (Singh & Chaturvedi, 2015).

...acupuncture has been found effective in addressing side effects frequently associated with pain... Successful use of acupuncture for pain management has occurred in a variety of patient populations, including those having acute and chronic pain (Faircloth, 2015), back and neck pain (Cho et al., 2015; Khatta, 2007; Trinh, Graham, Irnich, Cameron, & Forget, 2016), joint pain (Khatta, 2007; Singh & Chaturvedi, 2015), and labor pain (Smith et al., 2020). Additionally, acupuncture has been found effective in addressing side effects frequently associated with pain, such as nausea, vomiting, fatigue, decreased quality of life, and anxiety (Faircloth, 2015; Singh & Chaturvedi, 2015).

Yoga can be viewed as another form of alternative medical systems as it has its origins in Ayurvedic medicine (Morone & Greco, 2007). Yoga involves moving through various body positions or exercises using controlled breathing, meditation, and body posture. The sequential positions are performed with the aim to increase flexibility and strength, while controlled breathing and meditation are geared to calm, focus the mind, and develop greater awareness (Morone & Greco, 2007). Additional benefits reported from yoga included reducing stress, improving mood, detoxification, increased quality of life, development of spiritual awareness, and a combination of these benefits (Lee, Crawford, & Shoemaker, 2014). Physiologically, yoga appears to not only stimulate muscles, but also increase blood and lymphatic flow in the body. The deep breathing associated with yoga increases oxygen delivery to cells as well as vital nutrients and removal of toxins (Singh & Chaturvedi, 2015).

Yoga has been studied in a variety of populations and has been found helpful to treat pain.Yoga has been studied in a variety of populations and has been found helpful to treat pain. Specifically, meta-analysis of studies of yoga in chronic pain, such as fibromyalgia and low back pain, reported reduced pain with yoga when compared to usual care (Lee et al., 2014). Yoga has demonstrated benefit in oncology patients with a positive impact on restoring motion and flexibility after surgery; improved mood and quality of life; and reduced depression and anxiety (Singh & Chaturvedi, 2015). A literature review by Morone and Greco found that yoga provided positive outcomes for older adults suffering from osteoarthritis with reduction in pain as well as improvements in physical functioning (Morone & Greco, 2007). Finally, a Cochrane review of the literature demonstrated that yoga providing a calming effect and supported women in managing pain and tension associated with labor (Smith et al., 2018).

Mind-Body Interventions
Two approaches considered mind-body interventions are the use of music and guided imagery/relaxation for pain management. Music listening can be employed to lower stress, anxiety, pain, and depression; foster relaxation; boost mood and movement; and alleviate boredom through diversion (Chlan & Halm, 2013). Music and music therapy have been applied in various populations and settings with overall positive results on decreasing pain, anxiety, analgesia use, and vital signs (Hole, Hirsch, Ball, & Meads, 2015; Lee, 2016; Li, Zhou, & Wang, 2017). Specific populations in studies of the effects of music on pain included patients from oncology (Keenan & Keithley, 2015), critical care (Chlan & Halm, 2013), obstetrics (Smith et al., 2018), as well as surgical (Hole et al., 2015), older (Bruckenthal, Marino, & Snelling, 2016), and burn patients (Li et al., 2017). The music should be flowing and instrumental with 60-80 beats per minute, consisting of low tones with strings and minimal brass percussion (Joanna Briggs Institute, 2011). Use of headphones allows uninterrupted listening for the patient and avoids interference with other patients’ environment.

Guided imagery has been noted to be a successful adjuvant for all ages Another mind-body intervention applied to pain management is guided imagery. Guided imagery can be defined as the “purposeful use of the imagination, using words and phrases designed to evoke rich, multisensory fantasy and memory” (Bonadies, 2009, p. 43). This form of focused relaxation has been used to enhance an individual’s coping abilities (Bruckenthal et al., 2016) and promote alterations in perception, sensation, emotion or thought (Bernardy, Fuber, Klose, & Hauser, 2011). When applied to pain management, guided imagery can produce a psycho-physiological state of relaxation that permits the patient to redirect his/her attention away from the pain (Turk, Swanson, & Tunks, 2008). Guided imagery has been noted to be a successful adjuvant for all ages (Bruckenthal et al., 2016; Morone & Greco, 2007). Positive results have been achieved in a variety of patient populations, including those with cancer-related pain (Singh & Chaturvedi, 2015), fibromyalgia (Bernardy et al., 2011; Meeus et al., 2015), joint pain (Khatta, 2007), chronic pain (Bruckenthal et al., 2016; Morone & Greco, 2007; Turk et al., 2008), and labor (Smith et al., 2018).

Natural Products
The body of knowledge regarding the impact of inflammation on health has grown. Chronic inflammation is now associated with both medical and psychiatric conditions, such as cardiovascular disease, metabolic syndrome, cancer, autoimmune disorders, schizophrenia, and depression (Tick, 2015). All of these conditions are adversely affected, along with overall wellness and life expectancy. A blood-marker of inflammation is C-reactive protein (CRP). Research has linked the presence of elevated levels of CRP with chronic pain, indicating a proinflammatory state (Macphail, 2015; Totsch, Waite, & Sorge, 2015). Measures to reduce the proinflammatory state include an anti-inflammatory diet, such as the Mediterranean diet (Bonaccio et al., 2017), and omega-3 fatty acid supplementation (Totsch et al., 2015).

The body of knowledge regarding the impact of inflammation on health has grown.Vitamin D deficiency has also been seen in those with chronic pain. Low vitamin D levels have been associated with low back pain as well as generalized pain states; thus correcting vitamin D deficiency has improved pain (Akyuz, Sanal-Toprak, Yagci, Giray, & Kuru-Bekfasoglu, 2017; Laupheimer, 2014). The proposed mechanism of vitamin D deficiency in pain is multi-factorial, including: muscle hypersensitivity; increased nociceptive skeletal muscle response; pro-inflammatory cytokine production; and dysfunction of pain suppression by the central nervous system (Macphail, 2015).

Manipulative and Body-Based Methods
Massage and chiropractic manipulation are two manipulative and body-based methods commonly used in pain management. Massage is the manipulation of muscles, connective tissue, tendons, and ligaments using manual techniques and the application of varying degrees of pressure and traction (Bruckenthal et al., 2016; Singh & Chaturvedi, 2015). Reduction of stress and anxiety levels and an increase sense of well-being are attributed to massage, which may thus contribute to pain control (Singh & Chaturvedi, 2015). Massage therapy has been successful in reducing cancer pain, chronic low back pain, labor pain, migraine headaches, arthritic pain, and fibromyalgia pain (Bruckenthal et al., 2016; Rodgers et al., 2015; Singh & Chaturvedi, 2015). Massage therapy is accessible in the outpatient arena, and an increasing number of hospitals offer this service for inpatients as well (Rodgers et al., 2015).

Chiropractic manipulation, or spinal manipulation, involves performing spinal and joint adjustments to influence the body’s nerves and natural defenses (Woodbury, Soong, Fishman, & Garcia, 2016). Chiropractic manipulation is used primarily to treat a range of musculoskeletal disorders (Khatta, 2007), most frequently low back pain (Kizhakkeveettil, Rose, & Kadar, 2014). The mechanism of action is elusive but manipulation appears to modulate pain through both central and peripheral pathways (Coronado et al., 2012). Metabolic changes in both the brain and skeletal muscles, along with a reduction in subjective pain and muscle tension, may also be associated with reduction in sympathetic nerve activity (Inami et al., 2017).

Energy Therapies
Energy, or biofield, therapies include therapeutic touch, healing touch, Reiki, and polarity therapy (Gonella, Garrino, & Dimonte, 2014). Each of these are defined in Table 3, based on the definition provided by the corresponding organization.

Table 3. Definitions of Energy Therapies Based on the Corresponding Organization

Energy therapies are based on a model that humans have an energy dimension and the focus of the therapy is to balance disturbances in the energy field (Gonella et al., 2014; Hammerschlag, Marx, & Aickin, 2014). Quantitative studies have indicated improvements in pain, depression, and anxiety while qualitative studies suggested improvement in individual coping resources and overall health outcomes (Gonella et al., 2014; Hammerschlag et al., 2014; Jibb et al., 2015).

Negative Aspects of Non-Allopathic Interventions

Non-allopathic approaches should not be viewed as an alternative to traditional pain management strategies, but rather as an adjuvant therapy...While there are many positive aspects to non-allopathic interventions for pain management, there are concerns to consider. Non-allopathic approaches should not be viewed as an alternative to traditional pain management strategies, but rather as an adjuvant therapy to reduce the burden of pain and potentially reduce medication usage. Unlike traditional medicine, the body of research is not as well established for many non-allopathic interventions (Chawla, 2020). Not all interventions are covered by insurance and the patient may have to make payment directly to a provider (Winter & Korzenik, 2017). This can cause a financial burden for the patient. Non-allopathic interventions may or may not be regulated by the Food and Drug Administration (FDA) or the Public Health Services Act (FDA, 2006). Finally, non-allopathic interventions do not work overnight. Results may not be apparent for several days or weeks.

Need for a Multimodal Approach

...effective pain management requires a multimodal approach, combining both allopathic and non-allopathic interventions Based on the recognized domains, I have provided a synopsis of the research regarding non-allopathic interventions applied to pain management. A final point is that effective pain management requires a multimodal approach, combining both allopathic and non-allopathic interventions (Delgado et al., 2014; Lee et al., 2014). Not only must the physical cause(s) of pain be addressed but also the psychological, spiritual, and social impact of the pain. Additionally, there must be a partnership between the patient and the interdisciplinary healthcare team. This partnership must empower patients in such a way that self-management is included in the treatment plan. Pain is a complex phenomenon; a 'one size fits all' approach will fail. An integrated approach is essential for treatment success.

Conclusion: Implications for Nursing Practice

Nurses frequently are caught in the middle between patients with unmet pain control needs and providers reluctant to prescribe opioids. As such, nurses serve as frontline advocates at a time when the patient is most vulnerable. Because patients are sometimes reluctant to disclose the use of complementary and alternative approaches, nurses must ask focused questions while completing their assessment regarding use of non-allopathic modalities. It is important to document these findings in the patient history and/or medication history (if herbal supplements) or as identified by the policies of the healthcare facility.

Nurses frequently are caught in the middle between patients with unmet pain control needs and providers reluctant to prescribe opioids.Nurses need to be very knowledgeable about complementary and alternative therapies when discussing interventions with patients. Because of the risk for drug-herbal interactions, a detailed medication history is essential, along with questions about herbal supplements and other over-the-counter medications the patient may utilize. If a patient wishes to pursue herbal supplementation, the nurse should recommend a conversation with a pharmacist or a provider trained in herbal supplements before proceeding.

Patient empowerment is also a priority when caring for patients with acute, chronic, or malignant pain.Patient empowerment is also a priority when caring for patients with acute, chronic, or malignant pain. Patient empowerment has been described as simply a process to help people gain control, which includes taking the initiative to solve problems and make decisions. It can be applied to different settings in health and social care, and self-management care (The Lancet, 2012). Empowerment approaches can include patient education, shared decision making, and self-management strategies. Studies have demonstrated that patient empowerment, patient education, and self-management have positive impacts on pain management for a variety of pain types (Collette, Spies, Eckardt, Wernecke, & Schmidt, 2016; Sullivan, et al., 2018). Resources for patients regarding non-allopathic pain management strategies are found in Table 4.

Table 4. Patient Resources for Non-Allopathic Pain Management Strategies

Empowerment of the patient in the healing process positively impacts the patient experience and delivery of nursing care. Patients may find a non-allopathic medicine practitioner in their area or within their healthcare system. Many states require licensure of non-allopathic medicine providers, such as acupuncturists and massage therapists. Patients should be encouraged to only use providers with licensure, if required by their state.

Patients should be encouraged to only use providers with licensure, if required by their state.With knowledge about non-allopathic interventions for pain, the nurse is equipped to evaluate evidence-based strategies, with possible incorporation into a holistic approach for pain control. Using a holistic and comprehensive pain management approach with patients may reduce complications. Table 5 lists resources to use when advocating for non-allopathic interventions for pain control.

Table 5. Resources for Non-Allopathic Interventions for Pain Control,

It is imperative for nurses to use evidence-based approaches to pain management regardless of whether or not non-allopathic modalities are used. Table 6 provides a list of current guidelines that maybe useful in the development of a comprehensive, pain management plan for acute, chronic, and cancer-related pain.

Table 6. Pain Management Guidelines

Patients deserve evidence-based, holistic pain management strategies as an option in their care.In sum, nurses must be advocates for patients. This may involve activities ranging from advocating for a holistic approach for an individual patient to policy level changes. Nurses are in a position to influence guidelines and policies so that non-allopathic modalities are classified by insurance plans as covered services and integrative medicine programs are developed within their healthcare facilities. Nurses have an opportunity for leadership by contributing to the body of knowledge and research about non-allopathic modalities through rigorous research studies and quality improvement projects. Patients deserve evidence-based, holistic pain management strategies as an option in their care.

Author

Linda Cole, DNP, RN, CCNS, CPHQ, CNE
Email: Linda.Cole@uth.tmc.edu

Linda Cole completed a Bachelor of Science degree in Nursing at the University of Southern Mississippi in Hattiesburg, Mississippi. She received a Master of Science degree in Nursing, with a focus on the Clinical Nurse Specialist role, and a Doctor of Nursing Practice degree from the Cizik School of Nursing at the University of Texas (UT) Health Science Center, UT Health, in Houston, Texas. Her doctoral capstone project focused on the impact of guided imagery on pain, anxiety, and analgesia use among hospitalized adults. She later implemented an integrative medicine program, including massage, acupuncture, and yoga relaxation, in an acute care hospital setting. Dr. Cole has presented at regional and national conferences about pain management and the use of integrative medicine approaches. She has published articles addressing integrative medicine in various nursing-related journals.