Finally! Integrative Clinician Will Lead NIH National Center for Complementary and Integrative Health … plus more

Finally! Integrative Clinician Will Lead NIH National Center for Complementary and Integrative Health

One astonishing sign of the prejudice that has guided the relationship between the US medical research establishment—as represented by the National Institutes of Health (NIH)—and the emerging complementary, integrative health and medicine fields is the choices made to direct what is now the National Center for Complementary and Integrative Health (NCCIH). Imagine the uproar if the NIH chose someone to direct the National Heart, Lung and Blood Institute someone who had no clinical or research experience with heart, lung, or blood. As noted in this review of past selections,¹ the NIH has done just that with its first 2 directors for complementary, alternative, and now integrative research. The first, Stephen Strauss, MD, knew nothing coming in, as either clinician or patient. He left nearly a decade later with his experiential ignorance intact. His successor, Josie Briggs, MD, came in ignorant but was honored widely for gaining experience of the fields and practices for which she would oversee up to $140 million per year of research investment. Yet even with Briggs’s openness, how “integrative”—and creatively so—can a mind think and dream if it is constructed of 3 decades of reductive rituals?

A sign of better things to come arrived after Briggs stepped down and longtime NCCIH senior staffer naturopathic physician Wendy Weber, ND, PhD, was named an acting deputy director during the interim was. Here was senior leadership in which professional preparation was paradigmatically appropriate. The disrespectful pattern was broken altogether with news in late August that Helene Langevin, MD, the director of the Harvard Osher Center for Integrative Medicine, was selected to succeed Briggs. Langevin—who also has also been a long-time member of the board of the Society for Acupuncture Research— through personal passion trained extensively with leaders of various branches of the acupuncture field: Five Element, Traditional Chinese Medicine, a European tradition, and more. Such immersion went well beyond the 200-hour Helms course that is the avenue of most medical doctors to acupuncture practice. She had a limited practice, for a period. She was at one time certified through the National Certification Commission for Acupuncture and Oriental Medicine, the standard bearer for licensed acupuncturists.

What got Langevin her position, however, was not her curiosity and practice experience of acupuncture. As a basic science researcher, Langevin’s intrigue with acupuncture’s mechanism earned her a global reputation for breakthrough research in understanding connective tissue. It was this experience that was cited by NIH director Francis Collins, MD, on Langevin’s appointment.² Now it will be up to the integrative health field to keep Langevin’s lens widened so she will engage the challenges in exploring the value in multimodal, individualized, health-focused, mind-and-body practice that are the hallmark of the fields from which she comes and that the NCCIH is nominally charged to explore. Perhaps just as it was the Republican, Richard Nixon, who opened relationship with Mao’s China, might the basic researcher, Langevin, leverage her credibility in the NIH’s sweet spot to drive significant resources toward the need to research the way integrative practitioners practice that has been left essentially fallow by her predecessors. Until that time, the gold in these practices will be left in them thar hills.

Are Integrative Practices in New Federal Pain Policy: Four Recent Initiatives

Over the half decade since the National Academy of Medicine’s first major, Affordable Care Act-driven rethinking of pain policy, Relieving Pain in America: A Blueprint for Transforming Prevention, C are, Education, and Research, the value of nonpharmacologic, complementary, and integrative approaches and practices has been on an upward, if wildly fluctuating, trajectory. The integrative language in the Blueprint marked a watershed.³ Yet now each new guideline and policy emitted from the Capitol is a Where’s Waldo? exploration to find out how it may or may not refects the substantial research supporting integrative practices for pain care. A broader examination elsewhere⁴ of 4 recent actions produced these recent snapshots.

The Opioid Crisis Response Act of 2018: (Virtually) No Mention in the Senate Version

On September 10, 2018, the US Senate HELP Committee published a 3.5-page executive summary of the version it passed of the Opioid Crisis Response Act of 2018.⁵ The very first charge is to the NIH to find a new, nonaddictive painkiller. That sets the tone. The 7 sections and 29 subsections of the summary do not include any explicit mention of “complementary” or “integrative” modalities or practitioners. What would be shocking—if we were not desensitized by the expectation of pro-pharma pandering of Congress—is that the term nonpharmacologic didn’t make the HELP memo at all. A separate 18-page memo²¹ with a section-by-section analysis of the mammoth piece of legislation, also from the US Senate, offers 2 very limited specific mentions that might please a street beggar: Section 1202 on “Pain Research” includes the briefest mention of nonpharmacologic treatments; and Section 1502 on Programs for Health Care Workforce “updates pain care programs to include alternatives to opioid pain treatment and by promoting non-addictive and non-opioid pain treatments, and non-pharmacologic treatment.” A call for Comprehensive Opioid Recovery Centers meant to “provide the full continuum of treatment for patients in areas hit hardest” pushes a door open, but with no specific references to non-pharma or integrative methods. (Note: This reporting relies on these 2 summaries.)

ShortTakes.

• ► Harvard Medical School is considering a change in its mission from a focus on “alleviating human suffering caused by disease” to “health and wellness for everyone.”⁶

• ► News arrived recently of the deaths of 2 significant, long-time influencers in the integrative space from the United Kingdom: from trauma of a bike accident, World Health Organization (WHO) traditional medicine adviser, homeopathy advocate, and the “Queen’s Physician” Peter Fisher, MD⁷; and from causes related to an unspecified illness, prolific natural health author and body worker Leon Chaitow, DO.⁸

• ► US trade wars with China have touched the botanical industry. The American Herbal Products Association has applied for relief for the herbal and dietary supplement industry from tariffs from China.⁹

• ► Credit this journal for making public a paper by longtime integrative medicine attorney Alan Dumoff on the compounding issue: “Food and Drug Administration Restrictions on Drug Compounding: Needed Medications are Going to Disappear: A Call for Intervention.”¹⁰

• ► The American Massage Therapy Association took small steps in the direction of professionalizing the field with $75 000 donated to a teacher certification program of the Alliance for Massage Education and $225 000 to assist schools to gain accreditation through the Commission on Massage Therapy Accreditation. The 75 000-member organization is reportedly sitting on $14 million of reserves.¹¹

• ► The Global Spine Care Initiative led by Scott Haldeman, MD, DC, PhD, has produced, through an international and interprofessional team of 68 professionals from 24 countries, a comprehensive, global model for spine care with special focus on low- and middle-income nations.¹²

• ► Led by Massachusetts acupuncturist and activist Amy Mager, MS, LAc, Dipl OM (NCCAOM), the American Society of Acupuncturists (ASA) has taken on the hottest legislative topic for the field in a concise 4-pager: “The Relationship Between Acupuncture & Dry Needling: Clarifying Myths and Misinformation.”¹³

• ► The International Association of Yoga Therapists, the organization that is guiding professional development of that field, has taken an additional step in the continuing education area by piloting its Approved Professional Development Program.¹⁴

• ► A Quick Safety Advisory #44 from The Joint Commission provides health care providers with several evidence-based, nonopioid treatment options for pain.¹⁵

• ► California Governor Jerry Brown has signed a law requiring hospitals to offer a plant-based meal option.¹⁶

• ► The Institute of Natural Medicine features a Naturopathic Medicine Patient Gallery with scores of headshots and short blurbs from grateful patients.¹⁷

• ► In a trend for Blues plans on both coasts, the new Anthem Blue Cross and Blue Shield Medicare Advantage plan boasts up to 24 acupuncture and/or therapeutic massage visits each calendar year.¹⁸

• ► Chiropractor Christine Goertz, DC, PhD, has been appointed to serve a 3-year term as vice chair of the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors. Credit the Affordable Care Act, which stipulated that PCORI include at least 1 licensed integrative medicine professional, and Goertz’s hard work since.¹⁹

• ► The multidisciplinary, functionally oriented American Congress of Rehabilitation Medicine now has an integrative medicine initiative according to one of the leaders, Ariana Vora, MD, of the Harvard-affiliated Spaulding Rehabilitation Hospital shares information on the organization.²⁰

National Academy of Medicine #1: Opioid Action Collaborative

On July 31, 2018, the National Academy of Medicine (NAM) announced that it was launching an “Action Collaborative to Counter Opioid Epidemic—Public-Private Partnership Will Coordinate Initiatives Across Sectors to Drive Collective Solutions.”²² On the NAM Web site for the initiative the title is, “Countering the Opioid Epidemic: NAM Action Collaborative.”²³ Despite NAM’s nominal interest in interprofessionalism, the steering committee consists of 5 medical doctors, a PhD, and an attorney. The list of “Participating Organizations” also puts NAM out of step with the era of interprofessionalism, with extension from MDs only to pharmacy and dentistry. Nursing is not represented, nor social work, nor major organizations for behavioral and mental health. Under NAM President Victor Dzao, MD, the patrician 1950s dominates. Medicine’s regression to a meanness of a reductive, monoprofessionalism is apparently continuing in full force. There is zippo related to non-pharma interests or practices.

National Academy of Medicine #2: Non-Pharma Approaches to Pain Management Workshop

Meanwhile, an additional NAM initiative, while more limited and lower profile, offers a wonderfully inclusive view of the future of pain treatment. On December 4-5, 2018, the NAM Global Forum on Innovation in Health Professional Education will cohost a workshop entitled “The Role of Non-pharmacological Approaches to Pain Management.”²⁴ The Global Forum is a profoundly interprofessional engagement with integrative fields represented through the Academic Collaborative for Integrative Health. The cochairs of the workshop are Kaiser Permanente’s Daniel Cherkin, PhD, a well-known researcher in complementary and integrative practices, and Anthony Delitto, PhD, PT, from the University of Pittsburg where he has a history of collaborative with chiropractor Michael Schneider, DC, PhD. The 2 paragraphs introducing the workshop’s purpose note the 2011 NAM document referenced at the top of this segment that the Collaborative influenced by successfully nominating acupuncturist and naturopathic doctor Rick Marinelli, ND, LAc, to the NIH’s committee. The Collaborative’s Elizabeth Goldblatt, PhD, MPA/HA, is on the present planning committee. The introductory language for the December workshop notes that it will “bring together key stakeholders to discuss these treatments and integrative health models for pain management.” The objectives are similarly well formed. This is good news. Unfortunately, the reports of such workshops do not have the weight that those of the Opioid Action Collaborative will.

US Food and Drug Association’s Opioid Risk Evaluation and Mitigation Strategy Includes Non-Pharma

The US Food and Drug Administration’s (FDA’s) Opioid Analgesic Risk Evaluation and Mitigation Strategy²⁵ announced September 18, 2018, significantly includes nonpharmacologic approaches and positively references “complementary therapies.” An evaluation of the strategy from Academy of Integrative Pain Management’s director of legislative and regulatory affairs, Katie Duensing, JD, shares examples of inclusion. A section on education of health care practitioners (HCPs) suggests that preparation should include both nonpharmacologic and pharmacologic therapies. A section on coverage urges HCPs who “encounter potential barriers to managing patients with pharmacologic and/or nonpharmacologic treatment options, such as lack of insurance coverage or inadequate availability of certain HCPs who treat patients with pain, attempts should be made to address these barriers.” A section on “General Principles of Non-Pharmacologic Approaches” lists various nonpharmacologic and self-management treatments that “include, but are not limited to, psychological, physical rehabilitative, and surgical approaches, complementary therapies, and use of approved/cleared medical devices for pain management.” The FDA notes that evidence for non-pharma is often better than for pharma. This list is not inclusive. The FDA’s 42-page strategy teaches that it serves none to assume that the FDA’s pharmaceutical bread and butter means it can’t sometimes promote the value of other methods.

Is it Time To Reexamine Guidelines for Integrative Medical Practice?

A thoughtful commentary²⁶ from 2 of soon-to-be NIH NCCIH director Langevin’s colleagues in the Osher Collaborative for Integrative Medicine, Melinda Ring, MD, FACP, and Sandy Newmark, MD, FAAP, wades into some of the most contentious terrain in integrative practice. Entitled “Practice Drift: Are There Risks When Integrative Medicine Physicians Exceed Their Scope?” the column describes how, in the chaotic emergence of the field, conventionally trained medical doctors can declare themselves an integrative expert on the basis of limited training while another may complete a 2-year fellowship before assuming the appellation. More to their point, in doing so, the medical doctor may stray into a specialty outside of that into which the doctor was formally trained. Ring and Newmark make clear that the purpose of the commentary “is neither to censor any particular group of providers nor to advocate for unreasonable restrictions on integrative practices.” (In fact, one witnesses an unusual level of interprofessional respect in one comment. The authors note that one risk from medical doctors’ rapid uptake of new modalities is to “alienate complementary providers” who may have completed years-long professional education in areas where medical doctors may have just a couple hundred hours of training.) They offer a half dozen suggestions, including transparency with patients about one’s level of education. The most significant is a recommendation that the Federation of State Medical Boards, following a decade and a half of robust development in the field, “revisit” the “Model Guidelines for the Use of Complementary and Alternative Medicine in the United States” that they issued in 2002.²⁷