The opioid epidemic is a growing issue in the United States, highlighting the struggle within the medical system to provide effective and non-addictive pain management options to patients.
Dr. Carla Kuon, MD, is a hospitalist and integrative medicine physician at UCSF, with a background in addiction medicine, who is focused on uncovering non-pharmacologic pain relief options for patients. She is already using acupuncture, massage, and guided imagery in patient treatments, and is working strategically to bring these integrative options to patients throughout the medical system.
I was a hospitalist before joining UCSF, and like many other hospitalists, I started seeing an increasing number of patients developing opioid dependence. I worked at St. Helena Medical Center, where the hospitalists ran an inpatient detox program. Once patients were stabilized, they were transferred directly to an outpatient 30-day program, where they would receive heavy cognitive behavioral therapy and group therapy. Initially, I was hesitant in treating patients with substance use disorders, because they had a lot of psychosocially complex issues that I didn’t feel equipped to manage. But I found that once I had the tools to detox these patients and get them on the path to move forward with other therapies, it was really rewarding. I felt like I was partnering with patients to help them get their lives back together, which is a really wonderful thing to be a part of. It was an empowering experience for me, and got me interested in learning how to better manage patients with substance abuse disorder.
I joined UCSF after working at St. Helena, as part of a bone marrow transplant (BMT) service. Patients were prescribed morphine opioids, Ativan and other psychotropic medications freely – cancer is one of the diagnoses where there’s no bar to what you can prescribe because there is no question the patients are suffering great pain. But some of my patients, especially the younger ones, started demonstrating signs of addiction, which was really concerning to me. There is a really big anxiety component to the pain, which I also noticed more in the younger patients because they are caught off guard confronting death so early in their life, and feel emotionally hijacked by the experience. In seeking non-pharmacologic options to relieve patient’s pain and anxiety, I started a massage service in the BMT service. It was a successful program, and patients were really appreciative. From there, I launched into working on uncovering what else we can offer patients to relieve their pain, anxiety and stress.
I’m a big believer in healthy diet and nutrition. I also have a family history of celiac disease, so I have great respect with how diet can really influence health. I have enormous respect for knowing the power of your body, knowing your genetics, and knowing what a healthy diet means for you. So, when I heard about the integrative medicine fellowship, I knew it was exactly what I wanted to do. Integrative medicine has everything that is interesting to me: it incorporates TCM, Ayurveda, nutrition, and mind-body components. It was just a really good fit.
I was always really interested in TCM. I took a beginner acupuncture course for physicians when I was at St. Helena, and started doing basic acupuncture on some patients voluntarily, because there was no way to bill for it. Acupuncture is clearly a very effective pain reliever for many conditions. So, that long-standing interest in TCM converged with my interest in alternative options for pain relief. I do ear acupuncture mostly, which is something I offer in the UCSF Women’s HIV Program, which has a high comorbidity of IV drug abuse as well.
I’ve read several articles that show that acupuncture increases pain thresholds and sensitivity to pain medications, and patients are able to cut down on methadone and other opioids when getting acupuncture. I also feel that a lot of people with substance abuse have some dissociative issues, and acupuncture is a great way to bring back body awareness. It’s also useful as a way to relax people if there’s an anxiety component. I consider it a very effective tool, and I’m hopeful that it will be increasingly incorporated in the treatment of patients with chronic pain.
Pain is really complex, so it requires complex management. Part of the mistake that physicians have made is that they treat pain primarily pharmacologically – but there’s a clear anxiety component to pain. People who have low pain thresholds often have a history of trauma or childhood abuse, so there is often a complex psychological component. There’s also a neuroplasticity component – the brain learns to get used to certain things. So an ideal pain treatment regimen would incorporate a number of different modalities to address the various aspects. There’s no single regimen that works for everyone, I think it does have to be tailored, and it has to be a multifactorial approach. I think acupuncture is a strong and important component of that.
One of my emerging passions is in genomics. I’m particularly interested in the genomics of sleep and nutrition, as well as pharmacogenomics – the interaction of genes with certain medicines. In patients with long-standing insomnia, I often discover, using genetic analysis, deficiencies in certain enzymatic pathways that convert tryptophan to serotonin and melatonin. It is really rewarding to get someone with “lifelong insomnia” sleeping fully through the night by only using a couple of over-the-counter supplements. So, if a patient has done a 23 and Me or Ancestry DNA test, I can download the raw genetic information and given them nutrition and supplement advice that can promote improved health and quality of life.
Reimbursement is a huge piece. I’m happy to see that more and more insurances are starting to reimburse acupuncture – that makes it much easier for me to recommend it to patients. One of my biggest struggles is that I have patients who have suffered from complex medical illness for many years, they have limited income and they’re barely getting by. It’s really hard to recommend that they pay for things out of pocket, like massage, acupuncture, or supplements. It’s possible that, with the opioid epidemic, insurance companies will realize that they need to support more integrative therapies to prevent this from escalating further than it has. It’s possible that we’ll see more doors opening in the future.
I do see a shift occurring within the medical community, and I think there are a couple of paths to progressing this shift. Firstly, physicians are frustrated with the opioid epidemic, and want to know what else they can do for pain patients. Physicians are afraid to treat pain because they feel they lack adequate tools, much how I felt before I became educated in addiction. I’m involved with a group of physicians who are starting an addiction service at UCSF that’s going to launch next year, and we’re going to start introducing acupuncture and guided imagery at that time. It’s going to be a great opportunity to make physicians aware of the additional tools that they can use for treatment and pain – and once they’re aware of these effective tools, they will be more likely to incorporate it into their plans for patients.
Another area for introducing integrative medicine is perioperative care. Studies show that patients that use guided imagery before surgery require less anesthesia and recover faster. I have started a guided imagery service at UCSF, and the perioperative people are already interested in incorporating guided imagery as well. By starting with the low hanging fruit, practitioners will realize that it can be a useful adjunct treatment for patients, and I think it will be more present in people’s awareness as a helpful tool.
I also think that nurses are the biggest advocates for patients. Nurses will offer any tools to their patients, if they think they can help – that is a powerful path of introducing integrative medicine into the culture. When introducing the massage service, I approached the nurses and told them it was something they could offer their patients, and they were the biggest supporters and drivers of the massage service.
It would be great if there was more communication and integration. Sometimes patients come to me, and they’re seeing an acupuncturist who is prescribing herbs, but the patient doesn’t know what the herbs are, so I don’t know what the herbs are. I always appreciate it when patients come in with a patient plan, including what herbs they’re on, because it helps me to coordinate care and cooperate as a team with the acupuncturist. I would definitely like to see more of that: more cooperation, more documentation so that we can all work together. I give all of my patients handouts on the things that I recommend for them, and they really appreciate that – they can take it to their oncologist and their acupuncturist, so they know what I’ve been recommending, and we can all congeal around one plan.
It would be great if we could figure out a way to all collaborate, especially with complex patients, and think of ourselves as a team to address all of the issues. Deep collaboration will probably be a greater part of care in the future, even with non-integrative physicians, so I’m excited about the possibilities for a team approach.
Research & Writing by Dr. Stephanie Albert
Dr. Stephanie Albert holds a Doctorate of Acupuncture and Chinese Medicine from the American College of Traditional Chinese Medicine in San Francisco, CA. She runs a private practice out of the Lotus Center in the Mission district of San Francisco, where she works with patients to address stress, insomnia, pain, women’s health issues, and other health complaints through acupuncture, herbal medicine and lifestyle modification. www.stephalbert.com
Editing by Jennifer Pierce
Jennifer Pierce is a second year doctoral candidate at ACTCM in San Francisco, CA with a background in marketing and public relations.
For more information on this topic, attend “Healing Our Community’s Opioid Crisis: Expert Panel Discussion” on Sunday, October 7 at CIIS. This event will bring together Chinese medicine, Western medicine, mental health, and addiction experts to discuss how practitioners and the community can address the growing opioid crisis and move toward a more integrated standard of care. Tickets: Eventbrite.