Integrative medicine, Samueli endowment/UC-Irvine, Pain management, Therapeutic order, Opioid crisis

Pathways to Healing

by Elaine Zablocki

STORY TITLE:

Checkered Progress in Integrative Medicine

When you ask John Weeks about current progress in integrative medicine he describes a checkered pattern. You might call it one step backward, two steps forward.

For example, the end of 2016 and the beginning of 2017 were marked by a number of closures. The Penny George Institute for Health and Healing closed its research department. The Samueli Institute, which produced a great deal of the evidence that led to the military and VA significantly engaging integrative strategies, announced it was shutting down. They had been two significant contributors to the research base, and their loss was felt. In New York, the Continuum Center for Health and Healing shut down. To Weeks, these changes signaled the end of an era. At the same time, new initiatives were developing, and new doors were opening.

Weeks has been a presence in integrative health and medicine since 1983 as chronicler, speaker, organizer, consultant, and executive. He publishes the Integrator Blog, the leading North American source on the field’s policy, education, business, and organizational activity. For the last 18 months, he’s been serving as editor-in-chief of the Journal of Alternative and Complementary Medicine, and he writes frequently for the Huffington Post.

Recently Weeks took the time to describe some important developments in integrative medicine for Townsend Letter readers. “These closures led many of us to reflect on the way isolated integrative medicine centers have never been fully integrated into medical delivery organizations,” he says. “They were a way to put forward complementary therapies as potential models without fully engaging the medical director and medical and administrative staff throughout the organization. Nowadays, we see integrative medical doctors and other practitioners taking on significant roles within these organizations, and they’re finding ways to use integrated therapies in fields such as pain treatment and oncology that most of us couldn’t have imagined 20 years ago.”

Meanwhile, it turned out the Samuelis had big ideas simmering. They announced a $200 million investment in new research and clinical initiatives at the University of California, Irvine. They plan $50 million as an initial investment, plus another $150 million as an endowment for long-term support. This initiative is particularly significant because it will create a broad, integrative health-focused program within a medical school. Weeks says, “It includes a clinical initiative on how to embed integrative thinking and practices more deeply in care delivery. This is a gutsy, ambitious program that could create a model for the nation, and it is designed as an enduring campaign. Since it is endowment-based, it could last forever.”

Surprisingly, this initiative was greeted with derision by a significant portion of the mainstream media, which described it as fraudulent medicine. “When they call the Samueli investment fraudulent and quackery, that is science denial,” Weeks says. He points to recent guidelines from highly respected medical institutions, which now recommend non-pharmacologic, integrative strategies as the initial treatments for pain.

The American College of Physicians updated its low back pain guideline to recommend that “physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.”

The Joint Commission 2015 revision of its pain standard recommends strategies that include acupuncture, massage, chiropractic, and relaxation therapies.

Mayo Clinical Proceedings published an “Evidence-Based Evaluation of Complementary Health Approaches for Pain Management,” offering scientific evidence for multiple integrative modalities and practices.

A Broader View of Health and Healthcare

Weeks praises the Samuelis because they take a broad view when they think about health, healthcare, and delivery systems. “Creating and supporting health depends on many factors in addition to clinical medicine,” he notes. One estimate suggests that healthcare is only responsible for 10% of someone’s health. Family genetics account for 30%, behavioral patterns account for 40% while social conditions are responsible for 15% and environmental exposures about 5%.

“When our goal is to actually increase the health of the people we’re serving, we need to take a view that includes lifestyle issues as well as broader things such as access to education, healthy food, and economic opportunity,” Weeks says. “When we invigorate clinical practice to include a strong focus on nutrition, mind-body practices, behavior change, awareness of toxins and environmental issues, then clinical practice will influence a wider range of the determinants of health. We begin to influence behavioral and environmental and even genetic components – which means a stronger impact from clinical care. This is a strong argument for integrative, naturopathic, and functional medicine practice that we don’t usually don’t see presented in these terms.”

The opioid crisis has sparked a real debate, a national readiness to reconsider what Weeks calls

“the therapeutic order.” The basic idea here – Weeks says he learned it from the naturopathic doctors though it’s also just common sense – is that you start by using non-pharmacological, natural, integrative therapies, practices, and practitioners. Then you use approaches that are challenging to the body, invasive, potentially harmful, only when necessary and appropriate.

So, what does “changing the therapeutic order” look like? Weeks cites Dean Ornish’s program for heart health as a model. “Ornish is saying we can reverse atherosclerosis with diet, group work, exercise and meditation. He’s got a full integrated package there. That’s what a real lifestyle push looks like. It’s not simply saying ‘take this pill and you might also consider going for a walk occasionally.’”

Another example might be the work of Dale Bredesen, who’s published work suggesting that the MEND protocol (Metabolic Enhancement for Neuro-Degeneration) can have a significant effect reversing memory loss due to Alzheimer’s disease. The protocol is complex and includes recommendations for an anti-inflammatory diet, eight hours of sleep per night, exercise, vitamins, antioxidants, natural remedies such as curcumin, and much more. The initial study only covered 10 subjects. Still, any hint that a combination of natural remedies could prevent or reverse Alzheimer’s disease sounds worth pursuing!

Weeks hopes that as the nation learns about putting non-pharmacologic, integrative practices first in care for chronic pain, we will also begin to think about the therapeutic order as a basic principle in other conditions.

Weeks’ takeaway, when he looks at the Ornish program and the MEND protocol, is that we need to take behavior change seriously and make it a priority in everyday healthcare. “At some moments there’s a pervasive resignation in mainstream medicine, as if people don’t really have the energy to change so let’s just give them what they want. However, in my experience, integrative practitioners believe that people really do want to change, and they deserve practitioners who will guide them towards change.”

Is it Time for Payment Reform?

Of course, one major challenge for noninvasive health promotion strategies is the current payment structure, which incentivizes surgical procedures, medications, and brief office visits. The current opioid crisis means that many organizations are taking a second look at the hidden costs of pharmaceutical-based healthcare. The Center for Disease Control and Prevention called for public comment while it was developing guidelines on opioid prescriptions for chronic pain. In response, many mainstream healthcare organizations pointed out that it is essential for payers to cover non-pharmacological approaches.

This September, the National Association of Attorneys General (NAAG) wrote to America’s Health Insurance Plans, urging health plans to change payment policies to support non-opioid pain management therapies. “Doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care,” reads the letter signed by 37 state and territorial attorneys general. They hope to start a dialogue with the insurance industry to discuss revised incentive structures. “The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable,” the letter says.

“This is a welcome initiative on the payment side,” Weeks says. “To have 37 of the nation’s attorneys general telling the insurance industry that they – the attorneys general – plan to work with insurance commissioners state-by-state to force broader coverage of integrative strategies is an announcement that the sheriff is in town.”

Then Weeks, who has helped organize policy activity on integrative health in multiple arenas, adds a practical activist note: “Of course, it will be very helpful if integrative health advocates get their organizations to knock on the doors of their attorneys general and announce that they are happy to be part of their posse in making these changes.”

Resources

The Integrator Blog

http://theintegratorblog.com/

The Journal of Alternative and Complementary Medicine

http://www.liebertpub.com/overview/journal-of-alternative-and-complementary-medicine-the/26/

Integrative Approaches to Alzheimer’s Disease

https://www.integrativepractitioner.com/whats-new/all-news/can-the-mend-protocol-elevate-integrative-approaches-to-alzheimers-disease/

Reversal of cognitive decline: A novel therapeutic program, by Dale E. Bredesen http://www.aging-us.com/article/100690/text

John Weeks – Recent Articles in the Huffington Post

• Shameful Media Response to the Samueli’s Visionary $200-Million Integrative Health Investment at UC Irvine. https://www.huffingtonpost.com/entry/shameful-media-response-to-the-samuelis-visionary_us_59c7d9a0e4b0b7022a646b73

• Wayne Jonas, MD, and the Closure of the Influential Samueli Institute: Next Steps. https://www.huffingtonpost.com/entry/wayne-jonas-md-and-the-closure-of-the-influential_us_58d013ede4b0537abd957351

• Penny George Institute & Allina: Big Changes in Nation’s Leading Integrative Health Model. https://www.huffingtonpost.com/entry/penny-george-institute–a_b_14351264.html

• AMA, Other Leading Medical Organizations Urge Insurance for Non-Pharma/Integrative Pain Care. https://www.huffingtonpost.com/entry/ama-other-leading-medical_b_13696232.html

Elaine Zablocki is the former editor of CHRF News Files.