Integrative medicine to treat pain
We sat with Dr Amaury Salavert, an authority in pediatric pain management, for a fascinating talk on pain ranging from assessment to treatments and the contributions Alternative and Complementary medicines can make.
This is part 4 of 6, where we discuss integrative medicine and other new trends in pain management. For an overview of the various type of pains and how to address them, see part 1. For an overview of the various treatments available, see part 2. For an overview of benefits and risks, see part 3.
Tell me more about combining conventional care with alternative medicine. What’s your take on it?
For me, integrative care is the future of medicine. Integrative care is an increasingly popular approach. For very good reasons. The advantages of this approach are numerous, including the empowerment of the patient to take an active role in their own care, as well as the low risk of adverse events associated with alternative treatments. Additionally, research has shown that integrative care can be more effective than pharmaceutical treatments when it comes to pain because the former is so much better at addressing its emotional aspects. Migraines for instance is a kind of pain where I have seen repeatedly the benefits of having an integrative approach.
What are the risks associated with using integrative care for pain management?
Same as alternative medicine, the most important thing to keep in mind is that the alternative part of integrative should be used in conjunction with the conventional part not replace it. It is also important to consider all parameters when treating pain, as it is like a web of threads that must be pulled together to achieve the best results.
What would you tell to physicians looking into integrative care for the first time?
Just try it. Maybe on yourself first if you have doubts. When it comes to incorporating these treatments into a child's treatment plan, the best strategy is just to try it and see if it works. Risks are extremely limited. If the integrative treatment doesn’t work, then a conventional pharmaceutical treatment should be used. If it does work, then it can be used as another weapon in the treatment arsenal.
What do you tell to patients when you want to introduce alternative treatments?
How do you introduce alternative treatments with families?
Families usually want alternative treatments. There is such a mistrust around conventional care these days that any alternative is in high demand. However, patients may not be used to the slower effects of alternative treatments, as they are often accustomed to powerful drugs that provide short-term relief.
Is that something that you'll tell patients and families? Be patient, be committed, will take time but you will get better?
I do. But it's extremely hard to hear. Let's say that you're in a bathtub full of snakes. You're told to breath deeply. That it can help ease the situation. You're also told that breathing deeply may not provide an immediate solution, that you have to be patient and consistent. Remember you're in a bath tube full of snakes because that's how chronic pain feels.
Have you found strategies to communicate this to your patients? How do you make sure they keep up their alternative treatments?
It's simple, I trust my patients not to keep up. It's my job to push for these treatments again and again every time I see my patients.
What trends have you noticed in pediatric pain treatments recently?
I'm not aware of any new trends. This is because it's difficult to test them on children due to the need for parental consent and the potential for negative outcomes. That's why pediatric pain is moving so slowly and why there are very few treatments available besides strong ones to start with. So you have limited option and alternative treatments are doing a great job at filling the gaps.
If you were given something new, something you don't know about, pharmaceutical or non-pharmaceutical, what are the things that you'll be very careful about?
For pharmaceuticals, it's important to be aware of the potential for addiction. This is especially true for pain management pharmaceuticals, which can be highly addictive. It is also important to understand the mechanism of the drug and to be aware of the potential long-term impacts.
This feels like we're talking about opioids. Are you hinting at some form of contriarian thinking here? Where opioids, old and new aren't always appropriate?
Opioids aren't appropriate most of the time for long term pain. When prescribing any long term treatment, it's important to reevaluate the treatment at every session to ensure it's working as intended and to consider lowering the dose or taking a break from the treatment. I think one of the problems of the opioid crisis was that many doctors were stuck with their patients telling them their condition was getting worse and worse. For them, things wer good at first then getting worse and worse. The lesson here is that in the case of opioids, it's important to consider switching to a different painkiller or opioid if the patient's condition is worsening.
So when do you know when to continue or when to switch?
Overall, I will always try to reduce painkillers. If a patient reports that their symptoms worsened after reducing their medication, it is important to ask questions to determine the cause. If the it's something else then pain, for instance the patient is now having difficulty sleeping, I might decide to lower the painkiller dosage and add something to help him/her sleep instead.
And how often to evaluate this?
Ideally 2-3 months because that's how long some effects might take to show up with integrative care. Like I said, it's important to be patient and keep track of the patient's progress.
You say there aren't many novely in the space. Where do you keep track of them?
I look at scientific societies and check websites such as UpToDate and PubMed. Pediadol is an exemple of trustworthy scientific society that I follow.