9

Complementary and Alternative Therapies in Comprehensive Chronic Pain Management

The workshop’s seventh session explored alternative and complementary pain treatments for chronic pain, the efficacy of those treatments, and how they can be integrated into conventional pain care to enhance physical, social, and psychological outcomes. The speakers were Tom Norris, retired Air Force lieutenant colonel and patient advisor with the American Chronic Pain Association; Peter Wayne, associate professor of medicine at Harvard Medical School and associate epidemiologist at Brigham and Women’s Hospital; Richard Harris, Susan Samueli Endowed Chair and professor at the University of California, Irvine; and Anna Woodbury, associate professor and vice chair of research in the Department of Anesthesiology at Emory University School of Medicine.

THE COMPLEMENTARY AND INTEGRATIVE PAIN MANAGEMENT TOOLBOX

Tom Norris, who retired from the Air Force after treatment for testicular cancer that led to chronic pain, has been living with chronic pain for 37 years. Through multiple failed surgeries and a decade using fentanyl, which he successfully tapered off of, Norris found purpose and support by connecting with others, facilitating support groups, and advocating for patient-centered care.

Norris discussed the complementary and integrative pain management (CIPM) toolbox developed by the Alliance to Advance Comprehensive Integrative Pain Management (2022; Figure 9-1). Comprehensive care, he said, should include physical, psychological, social, spiritual, and lifestyle

elements. Though insurance does not cover all of these therapies, they still matter and can help someone live with chronic pain. He noted that most people living with chronic pain are unaware of all the components of effective pain control. Moreover, they struggle to be believed, cannot work, and are denied recognition and insurance coverage because they are living with a terrible, stigmatizing, and invisible disease.

When dealing with his chronic pain, Norris said he tried almost everything. The challenge, said Norris, is that the Social Security Administration (SSA) may recognize some therapies, such as epidural injections and psychotherapy, but others, such as journaling, virtual reality, and peer support, often are not recognized, even when they help people function, and only when they are formally prescribed or documented in the medical record.

Norris listed several barriers to achieving effective pain management. Complementary and alternative medicine therapies, for example, often go undocumented in medical records, while insurance rarely covers non-opioid options. Fragmented provider communication is another barrier. He noted

the SSA disability system faces unique challenges given that chronic pain is often invisible, and treatment approaches such as yoga or pacing may be misread as full ability. Complementary and alternative medicine are often unrecognized unless formally prescribed, and people may fear reporting progress, worrying that doing so could jeopardize their benefits.

One model that works is the Veterans Administration (VA) Whole Health approach, which integrates complementary and alternative medicine therapies as core pain management tools. The Whole Health model empowers veterans to lead their care using evidence-informed and patient-centered treatments. He wondered if SSA could adopt similar approaches, such as acupuncture, massage therapy, mindfulness, biofeedback, tai chi, or yoga. He noted that when a system listens to science and lived experience, patients benefit.

Norris’s take-home messages for SSA were that chronic pain is real, complex, and personal, with everyone feeling and interpreting pain differently. Effective communication is one important key to effective pain management, while validation and compassion are powerful support tools. The best care, he said, is flexible and accessible, and SSA should support—not penalize—people using complementary and alternative approaches to manage their chronic pain.

MINDFUL MOVEMENT FOR CHRONIC PAIN

Chronic pain, said Peter Wayne, is a complex condition best viewed as a biopsychosocial challenge affecting the body, mind, and social engagement (Dueñas et al., 2016); mindful movement interventions such as tai chi, yoga, and contemplative dance can help address each of its facets. Mindful movement, he explained, is distinct from conventional exercise and seated meditation. Rather, it is a form of movement or body positioning that includes a cleared state of mind, with the goal of achieving deep states of relaxation and breathing (Larkey et al., 2009) and heightened body and psychophysiological awareness (Osypiuk et al., 2018). Mindful movement, said Wayne, is best viewed from an embodied cognition framework in which mental and physical experiences co-create one another (Schmalzl and Kerr, 2016; Osypiuk et al., 2018).

Mind-body movement practices such as tai chi, said Wayne, are multimodal, biopsychosocial mode-informed interventions with multiple components (Figure 9-2; Wayne and Fuerst, 2013). These components stimulate musculoskeletal tissues through movement and diverse postures while heightening somatic attention and mental focus. Imagery, visualization, breathing, autonomic regulation, higher level cognitive strategies such as kindness and self-gratitude, and psychosocial and physical interactions combine to enhance physical and psychosocial function, producing greater

interoceptive and exteroceptive acuity, healthier pain appraisal skills, and enhanced safety, self-efficacy, and adherence. Taken together, the end result is reduced pain and pain interference, said Wayne.

With more than 3,000 peer-reviewed articles on tai chi and qigong alone, the evidence supporting this approach to pain management is growing. One review he and his colleagues conducted of 210 systematic reviews of controlled trials, for example, found that “Tai Chi has multidimensional effects, including physical, psychological and quality of life benefits for a wide range of conditions, as well as multimorbidity. Clinically important benefits were most consistently reported for Parkinson’s disease, falls risk,

knee osteoarthritis, and cerebrovascular and cardiovascular disease including hypertension” (Yang et al., 2022).

Wayne reviewed a wide range of studies pertaining to the benefits of tai chi/qigong (TCQ) for several chronic musculoskeletal pain conditions. One review of 16 randomized controlled trials of TCQ for knee osteoarthritis found, for example, that TCQ produced improvements in pain and physical function that were greater than passive approaches (Kelley et al., 2022); another study comparing the effectiveness of TCQ versus physical therapy for knee osteoarthritis found that tai chi and physical therapy both improve pain and function scores, but only tai chi produced improvements on depression (Wang et al., 2016). Studies have also shown TCQ and meditation were helpful at managing low back pain (Yang et al., 2024) and neck pain (Lauche et al., 2016; Kong et al., 2022). Interoception—the body’s ability to sense and interpret signals from within and provide awareness of internal states such as hunger, thirst, pain, and emotions—is a key mechanism linking mind-body practices and pain management, said Wayne (Voss et al., 2023).

Wayne said that mindful movement interventions are promising for reducing pain and disability across multiple musculoskeletal conditions, though more high-quality randomized controlled trials are warranted. It is unclear, for example, whether mindful movement interventions are more efficacious or safer than conventional exercises. Heightened body awareness and affective attention may enhance somatosensation and pain appraisal, which may then mediate clinical benefits directly through biomechanical efficiency, for example, and indirectly via safety, enjoyability, adherence, and mood. Larger studies powered for mediation analysis, factorial trial designs, and mechanistic studies are needed to inform relevance of top-down versus bottom-up training components.

ACUPUNCTURE AND ACUPRESSURE FOR CHRONIC PAIN

Richard Harris noted that more people live with chronic pain than with cancer, heart disease, and diabetes combined, with an estimated cost of $635 billion in the United States. It is one of the major reasons for individuals to try integrative medicine, including acupuncture, meditation, and TCQ, cited Harris. He noted the share of U.S. adults who used integrative health therapies increased from 19.2 percent in 2002 to 36.7 percent in 2022 (Nahin et al., 2024). Acupuncture as a treatment for pain rose from approximately 55 percent of individuals experiencing pain in 2002 to 73 percent in 2022, an increase that may have occurred because of insurance coverage for acupuncture and the availability of more studies showing efficacy (Nahin et al., 2024).

One of the early studies on the efficacy of acupuncture in managing pain showed the analgesic effect of acupuncture is greatest from several

hours to two days after treatment, said Harris (Price et al., 1984). Studies have also shown that acupuncture significantly affects pain from migraines, osteoarthritis, and lower back and neck pain, with effect sizes that are larger than obtained with nonsteroidal anti-inflammatory agents (Vickers et al., 2012). Imaging studies have shown, too, that acupuncture deactivates the limbic system (Hui et al., 2000; Hui et al., 2005).

Though the evidence shows acupuncture is effective as a pain management technique, there are barriers to widespread adoption. One barrier is that many physicians do not know how to refer their patients to an acupuncturist. Harris said the National Certification Commission for Acupuncture and Oriental Medicine is a good place to start.¹ For individuals who do not live near a certified acupuncturist, Harris said there is an emerging body of evidence that self-acupressure using one’s thumb might be effective for certain symptoms, including fatigue and sleep difficulties (Zick et al., 2016). Learning this technique takes approximately 15 minutes, he added. Harris and his colleagues have developed a self-acupressure smartphone app.

INTEGRATIVE SOLUTIONS FOR PAIN AND DISABILITY IN THE VETERANS ADMINISTRATION

U.S. veterans, said Anna Woodbury, experience higher rates and prevalence of chronic pain and more severe pain compared to nonveterans, with 9.1 percent of veterans living with severe pain (Taylor et al., 2024). She explained that integrative medicine combines conventional therapies, such as drugs and surgery, with complementary therapies, such as acupuncture and yoga. Since 2010 complementary and integrative health has been part of the VA’s approach to treating pain in veterans, incorporating complementary evidence-based approaches such as massage therapy, acupuncture, mindfulness, tai chi, hypnosis, biofeedback, guided imagery, and yoga.² For example, evidence synthesized in 2023 showed that massage was likely to benefit veterans with chronic low back pain, fibromyalgia, and myofascial pain.

She noted the VA has implemented battlefield acupuncture, developed in 2001 to address acute and chronic pain, throughout its system. Battlefield acupuncture groups five acupuncture points on an individual’s ear in a certain sequence capable of being deployed on the battlefield. A retrospective analysis involving more than 11,000 veterans found that over three-quarters of those treated experienced an immediate decrease in

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¹ Available at www.nccaom.org (accessed May 13, 2025).

² VA Management briefs summarize the evidence supporting different complementary approaches the VA has adopted and are available at https://www.hsrd.research.va.gov/publications/management_briefs/default.cfm (accessed May 14, 2025).

pain, with an average decrease of 2.5 points (Zeliadt et al., 2020). This effect was smaller in veterans who had used opioids in the previous year. She noted that transauricular vagus nerve stimulation, which may operate on the same principle as battlefield acupuncture but uses a portable device that delivers mild electrical stimulation, is being developed to treat chronic pain (Patel et al., 2022). Certain VA centers also offer cranial electrotherapy stimulation, a device approved by the Food and Drug Administration for treating depression, anxiety, and insomnia, with some evidence showing it can decrease pain (Tan et al., 2011).

Woodbury said she hoped the rest of the U.S. health care system would follow the VA’s lead and offer more complementary and integrative approaches to individuals living with chronic pain. In particular, she said, the public would benefit from battlefield acupuncture as an easy and rapid approach with proven benefits.

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