Originally published by our sister publication Pain Medicine News

Taking the findings from recent studies, interventions such as yoga and acupuncture are evolving from “complementary” to becoming more accepted as viable alternatives for pain management for many patients.

The use of complementary health approaches to manage pain has surged in recent years, according to a study of trends over two decades by the National Institute of Health’s National Center for Complementary and Integrative Health (NCCIH) (JAMA 2024 Jan 25. doi:10.1001/jama. 2023.26775).

“This shift in utilization coincides with increased pain prevalence nationally and may be attributable to several factors, including randomized clinical trials suggesting that some provide low or moderate levels of pain management,” study lead author Richard Nahin, MPH, PhD, a lead epidemiologist at the NCCIH, in Bethesda, Md., and colleagues observed.

The increasing number of clinical trials investigating evidence for efficacy of complementary health approaches is due to the establishment and growth of the NCCIH. According to figures provided by the NCCIH press office, the NIH’s investment in researching pain specifically, among several other indications, went from approximately $479 million in 2012 to $978 million in 2022.

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On the question of whether there are particular complementary health approaches that are prioritized for research funding, Nahin told Pain Medicine News, “There has to be at least some evidence of clinical efficacy before we will spend taxpayer money looking at these things.”

In addition to the increasing number of trials conducted to ascertain efficacy, Nahin and colleagues suggested that other factors for the increased utilization of complementary health approaches for pain management include their incorporation into best-practice pain management guidelines, the need to mitigate use of potentially harmful opioids, and the increase in access to and insurance coverage of some complementary health approaches.

“The perfect example of this is acupuncture,” Nahin related. “Before 1974, there were no professional acupuncturists in the United States. Starting in 1974, that’s when the first four states began to license acupuncturists, and it became a recognized medical profession in the United States. As the number of licensing states have increased—up to 47 now—acupuncturists have moved to these states, and people now have access to them and they begin to use them.

“And then, reimbursement is very important. About two or three years ago, Medicare started reimbursing for acupuncture for back pain management. That’s a big deal,” Nahin emphasized.

“Once Medicare starts reimbursing for something, the private insurers are going to start. I’m sure over time we’re going to be seeing increased use of acupuncture by the elderly population,” Nahin said.

Tracking Trends in Use

The study by Nahin and colleagues tracked use of complementary health overall, and for pain management specifically, from data gleaned from the 2002, 2012 and 2022 National Health Interview Survey—an annual, nationally representative, cross-sectional household interview conducted in person and by telephone.

There were over 31,000 and 34,000 respondents in 2002 and 2012, respectively, which decreased to 27,651 in 2022. Statistical analysis of the data included producing sample weights to account for nonresponse.

Age-standardized prevalence of overall utilization and for pain management specifically were compared across the three surveys for acupuncture, chiropractic care, guided imagery, and/or progressive muscle relaxation, massage therapy, meditation, naturopathy and yoga. An exception was the 2012 data for chiropractic care and for meditation, which were not included in the comparison, as the questionnaire wording for these two complementary health approaches had been substantially changed in 2012.

Nahin and colleagues reported that among respondents reporting use of any of the seven approaches, the percentage of use for pain management increased significantly, from 42.3% (95% CI, 40.8%-43.8%) in 2002 to 49.2% (95% CI, 48.0%-50.3%) in 2022. A statistically significant increase was found with each of the seven approaches, with yoga having the largest increase in pain management, from 11.4% (95% CI, 9.3%-13.6%) in 2002 to 22.8% (95% CI, 20.4%-25.1%) in 2022. Chiropractic care was the most frequently used complementary health approach for pain management in 2022, at 85.7% (95% CI, 84.2%-87.2%).

Meditation had the highest prevalence for overall use, with 17.3% (95% CI, 16.7%-17.9%) of respondents in 2022. Yoga had the largest increase for overall use, as it did for pain management, with 5.0% (95% CI, 4.7%-5.2%) in 2002 to 9.0% (95% CI, 8.6%-9.4%) in 2012, and 15.8% (95% CI, 15.2%-16.3%) in 2022. The increased prevalence of acupuncture likely reflected increased insurance coverage, rising from 1.0% (95% CI, 0.9%-1.2%) in 2002 to 1.5% (95% CI, 1.3%-1.6%) in 2012, and 2.2% (95% CI, 16.7%-17.9%) in 2022.

The increased use of complementary health approaches for pain was a welcome, albeit not unexpected finding, in the view of Beth Darnall, PhD, a professor of anesthesiology, perioperative and pain medicine, and the director of the Stanford Pain Relief Innovations Lab at Stanford University School of Medicine, in California.

“Multiple federal agencies have called for better integration of evidence-based ‘whole health’ approaches into pain care pathways,” Darnall told Pain Medicine News.

“Results of this study suggest progress with expanded access to various types of care, though we still have a long way to go. Improved insurance coverage is needed across a variety of evidence-based treatments used for pain management, with behavioral health services, such as pain psychology, being a prime example,” she said.

In additional discussion, Nahin contrasted the increased use of complementary health approaches for pain with findings from his earlier study that traditional approaches for pain management had declined over approximately the same time period.

“At the same time that pain [prevalence] is going up, the number of office visits for pain was going down; hospitalizations for pain were going down; ER visits for pain were going down. Since about 2001 or 2002, use of any prescription for pain was going down, and since about 2005 or 2006, the use of [prescribed] opioids has been going down,” Nahin said. (In an earlier study, Nahin et al had noted that the reported decrease in prescribed opioids was primarily driven by decreased use of less potent opioid products [J Pain 2019;20(7):796-809]).

—Kenneth Bender