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Excerpt from INFLAMMATION MASTERY, 4TH EDITION
Inflammation Mastery 4th Edition is available from BookDepository, Amazon.com, Barnes and Noble, ThriftBooks, AbeBooks, BetterWorldBooks, WaterStonesBooks
Introduction to Basic Musculoskeletal Care and Integrative Nonpharmacologic Pain Management: Whether dealing with a recent and acutely painful injury or an exacerbation of a chronic injury or musculoskeletal disease, all integrative clinicians are wise to have at their disposal a comprehensive protocol for the management of acute and subacute pain and exacerbations of joint inflammation. Undertraining and incompetence in musculoskeletal medicine are very common among healthcare providers[1],[2],[3],[4],[5], leaving doctors to overuse simplistic and dangerous treatments (i.e., pharmaceutical drugs) because they are unaware of better options.[6] Failure to understand how to arrive at an accurate diagnosis and subsequent failure to know how to manage musculoskeletal pain leaves doctors and thus their patients with "no other option" than the overuse of so-called anti-inflammatory drugs such as non-steroidal anti-inflammatory drugs (NSAIDs, such as aspirin), which kill at least 17,000 patients per year[7], and the cyclooxygenase-2 inhibiting drugs (COX-2 inhibitors, coxibs, such as Vioxx and Celebrex) which have killed tens of thousands of patients.[8],[9],[10],[11]
Opioid epidemic in the United States (Pain Physician. 2012 Jul[12]): "Over the past two decades, as the prevalence of chronic pain and health care costs have exploded, an opioid epidemic with adverse consequences has escalated. …dramatic increases in opioid use… …aggressive marketing by the pharmaceutical industry. These positions are based on unsound science and blatant misinformation, and accompanied by the dangerous assumptions that opioids are highly effective and safe, and devoid of adverse events when prescribed by physicians. ... The escalating use of therapeutic opioids shows hydrocodone topping all prescriptions with 136.7 million prescriptions in 2011, with all narcotic analgesics exceeding 238 million prescriptions. It has also been illustrated that opioid analgesics are now responsible for more deaths than the number of deaths from both suicide and motor vehicle crashes, or deaths from cocaine and heroin combined. ... The majority of [opioid-induced] deaths (60%) occur in patients when they are given prescriptions based on prescribing guidelines by medical boards, with 20% of deaths in low dose opioid therapy of 100 mg of morphine equivalent dose or less per dayand 40% in those receiving morphine of over 100 mg per day. In comparison, 40% of deaths occur in individuals abusing the drugs obtained through multiple prescriptions, doctor shopping, and drug diversion. ... The obstacles that must be surmounted are primarily inappropriate prescribing patterns, which are largely based on a lack of knowledge, perceived safety, and inaccurate belief of undertreatment of pain."
Influence of profiteering public and private interests in drug regulation (The Nation 2014 July[13]): "Prescription opioids…are the most dangerous drugs abused in America, with more than 16,000 deaths annually linked to opioid addiction and overdose. The Centers for Disease Control and Prevention report that more Americans now die from painkillers than from heroin and cocaine combined. … People in the United States, a country in which painkillers are routinely overprescribed, now consume more than 84 percent of the entire worldwide supply of oxycodone and almost 100 percent of hydrocodone opioids. In Kentucky, to take just one example, about one in fourteen people is misusing prescription painkillers…."
The crisis in pain medicine and rheumatology: The epidemic of opioid overuse, the paucity of musculoskeletal training among medical physicians, the spike in analgesic and anti-inflammatory drug-related deaths, and the heightened costs of treating musculoskeletal conditions compared with other conditions[14] are summatively contributing to what is now called a crisis in pain medicine[15] and rheumatology[16]. For these reasons—and the humanitarian need to alleviate human suffering—this chapter provides an important review of nondrug treatments for musculoskeletal pain.
Previously, any medical treatment that was non-surgical was commonly described as “conservative” simply because it was non-invasive/non-surgical. However, many so-called “conservative” drug treatments are dangerously lethal and expensive, as the coxibs (cyclooxygenase-2 inhibitors), with their lethality and high costs, have demonstrated. Further, “conservative” has become such a confusing term in modern politics that even people who identify themselves as such are often at a loss for an accurate definition of the term. This updated version of this chapter will provide an expedient review of clinically relevant considerations in the management of pain and should be used in conjunction with the information in other chapters and volumes of this work.
The audience for this book—health science students and healthcare providers—should already be familiar with the components of basic care for injuries and the popular—yet overly simplistic—r.i.c.e. acronym, which stands for rest, ice, compression, elevation and is an easy and convenient approach to managing minor injuries, such as occurs during sports/athletics, e.g., the classic sprained ankle. When I taught Orthopedics at Bastyr University in 2000, I expanded this list to include protect, prevent re-injury, relative rest, ice, individualize treatment, compression, elevation, establish treatment program, anti-inflammatory and analgesic treatments, treat with physical/manual medicine, uncover the underlying problem, re-educate, rehabilitate, retrain, resourcefulness, return to active life, and nutrition including diet and nutritional and botanical supplements. The mnemonic acronym spells p.r.i.c.e. a. t.u.r.n. which is cumbersome but perhaps easy to remember and therefore useful; the major point is to think outside of the r.i.c.e. box. As integrative doctorate and multidoctorate clinicians, we certainly have much more to offer our patients than rest, ice, compression, and elevation; this chapter reviews some of these options using an outline based on the previous p.r.i.c.e. a. t.u.r.n. acronym and then concludes with the more pleasant b.e.n.d. s.t.e.m.s. acronym which was graphically demonstrated on the first page of this chapter.
Whereas the allopathic/drug-based approach stops with minimal pain/injury treatment and provides essentially nothing in terms of prevention or comprehensive patient management—let alone promotion of optimal health—the holistic and integrative approach is centered on the patient and seeks to help him/her attain optimal health while being treated for the musculoskeletal disorder. We can and must help our patients attain optimal health while effectively managing their acute and chronic musculoskeletal problems.[17],[18],[19] Indeed, since for many patients their only interaction with the healthcare system is when they are injured or in pain, we must seize upon this opportunity to enroll patients in preventive and pro-active healthcare; the alternative to proactive healthcare (maintaining/optimizing health and addressing health problems before they start or are still small) is reactive healthcare (managing problems after they have fully developed), which is now proven to be a colossal failure in terms of finances, health outcomes, resource utilization and other ethical considerations.
[1] Joy EA, Hala SV. Musculoskeletal Curricula in Medical Education: Filling In the Missing Pieces. The Physician and Sportsmedicine. 2004; 32: 42-45
[2] Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80(10):1421-7
[3] Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002;84-A(4):604-8
[4] Matzkin E, Smith ME, Freccero CD, Richardson AB. Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am. 2005 Feb;87-A(2):310-4
[5] Schmale GA. More evidence of educational inadequacies in musculoskeletal medicine. Clin Orthop Relat Res. 2005 Aug;(437):251-9
[6] See Vasquez A. Integrative Orthopedics, Third Edition (2012), Fibromyalgia in a Nutshell (2012), Inflammation Mastery and Integrative Rheumatology, Third Edition (2014)
[7] Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med. 1998;105(1B):31S-38S
[8] "The results from VIGOR showed that the relative risk of developing a confirmed adjudicated thrombotic cardiovascular event (myocardial infarction, unstable angina, cardiac thrombus, resuscitated cardiac arrest, sudden or unexplained death, ischemic stroke, and transient ischemic attacks) with rofecoxib treatment compared with naproxen was 2.38." Mukherjee D, Nissen SE, Topol EJ. Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA. 2001 Aug 22-29;286(8):954-9
[9] Topol EJ. Failing the public health--rofecoxib, Merck, and the FDA. N Engl J Med. 2004 Oct 21;351(17):1707-9
[10] Ray WA, Griffin MR, Stein CM. Cardiovascular toxicity of valdecoxib. N Engl J Med. 2004;351(26):2767
[11] "Patients in the clinical trial taking 400 mg. of Celebrex twice daily had a 3.4 times greater risk of CV events compared to placebo. For patients in the trial taking 200 mg. of Celebrex twice daily, the risk was 2.5 times greater. The average duration of treatment in the trial was 33 months." FDA Statement on the Halting of a Clinical Trial of the cox-2 Inhibitor Celebrex. fda.gov/bbs/topics/news/2004/NEW01144.html Available on January 4, 2005
[12] Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician. 2012 Jul;15(3 Suppl):ES9-38
[13] Fang L. The Real Reason Pot Is Still Illegal. The Nation 2014 July 21-28 thenation.com/article/180493/anti-pot-lobbys-big-bankroll. For additional social context see JF. What civil-asset forfeiture means. The Economist 2014 Apr 14 economist.com/blogs/economist-explains/2014/04/economist-explains-7
[14] European League Against Rheumatism. Higher health care cost burden of musculoskeletal conditions. eurekalert.org/pub_releases/2014-06/elar-hhc061114.php. 2014 Jun
[15] "The main causes of this crisis are: 1) the high prevalence of chronic pain, reaching levels of 17% in the adult population;2) the lack of appropriate training of primary care physicians in the field of chronic pain management; and 3) the paucity of consultation services in the field of chronic pain." Minerbi et al. Pain Medicine in Crisis—A Possible Model toward a Solution: Empowering Community Medicine to Treat Chronic Pain. Rambam Maimonides Med J. Oct 2013; 4(4): e0027
[16] Morris AJ. The approaching crisis in rheumatologic care. J Rheumatol 2003; 30: 1890
[17] Vasquez A. New Insights into Fatty Acid Supplementation and Its Effect on Eicosanoid Production and Genetic Expression. Nutritional Perspectives 2005; January: 5-16
[18] Vasquez A. Improving overall health while safely and effectively treating musculoskeletal pain. Nutritional Perspectives 2005; 28: 34-38, 40-42
[19] Vasquez A. The Importance of Integrative Chiropractic Health Care in Treating Musculoskeletal Pain and Reducing the Nationwide Burden of Medical Expenses and Iatrogenic Injury and Death: A Concise Review of Current Research and Implications for Clinical Practice and Healthcare Policy. The Original Internist 2005; 12(4): 159-182
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