Complementary and Integrative Management of Pain

Introduction and Explanation of Need

Chronic pain is the condition for which adults in the United States most often use complementary and integrative health approaches. Under normal circumstances, pain is an important physiological response that serves as a warning of actual or potential tissue damage. Chronic pain can indicate ongoing tissue damage, such as inflammation, or can persist due to central nervous system sensitization resulting from increased neuronal and circuit activation in nociceptive pathways even after the tissue has healed. As a chronic syndrome, pain adversely affects function and psychological and social well-being. Pain is most often treated with pharmacologic and/or surgical interventions. However, these treatments are often associated with adverse outcomes, including tissue damage following surgery and harmful side effects associated with pharmacologic treatment, such as risk of misuse and addiction, particularly in the case of treatment with opioids. Complementary and integrative health approaches to pain management may offer safer, more effective, and cost-efficient options.

NCCIH has focused on research related to chronic pain since the publication of its last strategic plan in 2016. Several programs have been initiated and led by NCCIH alone (e.g., the Exploring the Mechanisms Underlying Analgesic Properties of Minor Cannabinoids and Terpenes program) or in collaboration with other NIH Institutes and Centers (e.g., the Trans-NIH Natural Products and Pain Working Group). NCCIH also participates in large trans-NIH and trans-agency pain initiatives, such as the NIH-DoD-VA Pain Management Collaboratory and HEAL, the latter of which aims to help stem the national opioid public health crisis by evaluating innovative therapies for pain management and improving treatment for opioid misuse and addiction. Although research evaluating the impact of complementary and integrative approaches on pain remains a priority for NCCIH, a deeper understanding of the mechanisms by which complementary approaches exert their effects and identification of therapeutic biomarkers are needed to optimize treatments and to predict those individuals or groups most likely to respond to specific treatments. Rigorous basic, mechanistic, translational, clinical efficacy, and implementation research is needed before complementary health approaches for pain management can become an integral component of standard care.

What Does Success Look Like?

• Advanced understanding of multisystem pain mechanisms and phenotypes (e.g., myofascial pain) and common comorbidities.
• Elucidation of mechanisms underlying overlapping pain conditions.
• Increased focus on health disparities in pain and greater inclusion of women, racial and ethnic minorities, and underserved populations in clinical trials/studies on pain.
• Expanded evidence base on the efficacy and effectiveness of complementary and integrative approaches for pain management.
• Increased understanding of the multisystem mechanisms underlying the effects of complementary and integrative approaches on pain.
• Leveraging HEAL and other trans-NIH and trans-agency programs to identify therapeutic biomarkers for complementary and integrative health approaches on pain.
• Improved methods for incorporating effective complementary and integrative approaches into standard care to treat pain and decrease the unnecessary use of opioids.

Priorities

Basic and Mechanistic Research

• Expand preclinical research elucidating the mechanisms of physical and/or psychological interventions for pain.
• Explore peripheral tissue mechanisms underlying the impact of complementary and integrative health approaches on acute and/or chronic pain management.
• Conduct research to elucidate the myofascial components of chronic pain as potential targets for complementary and integrative health interventions, such as force-based interventions (e.g., manual and movement-based therapies).
• Conduct basic research to elucidate mechanisms underlying musculoskeletal pain.
• Identify novel, nonaddictive dietary supplement candidates to manage pain.
• Conduct basic research to elucidate the biological mechanisms that underlie the analgesic properties of natural products and their derivatives.
• Develop an understanding of how complementary health approaches impact multiple biological systems that may be involved in chronic pain conditions (e.g., brain-gut-microbiome, myofascial tissue-brain).
• Study behavioral, psychological, social, and physiological mechanisms underlying complementary and integrative health interventions for pain management in specific populations, including underserved populations and those underrepresented in research (e.g., people with sickle cell disease pain, children, older adults, women, military personnel/veterans).
• Identify mechanistic targets for complementary and integrative health approaches to treat acute pain conditions and prevent development of chronic pain.

Biomarkers

• Develop and validate biomarkers that assess therapeutic responsiveness to complementary and integrative health interventions or predict efficacy of these approaches in the treatment of pain, leveraging HEAL and other trans-NIH and trans-agency programmatic efforts.
• Develop and validate diagnostic and prognostic biomarkers with potential applications for complementary and integrative health approaches in selected populations (e.g., minorities, women, underserved populations, children, older adults).
• Develop quantitative evaluations and biomarkers of myofascial pain.

Clinical Research

• Expand clinical research to determine the analgesic potential of natural products.
• Conduct clinical research on complementary and integrative health approaches in selected populations (e.g., minorities, children, women) to address pain disparities.
• Examine interactions of multicomponent nonpharmacologic interventions (e.g., meditation and probiotics), alone or in combination with pharmaceuticals, to optimize efficacy.
• Expand implementation research to study how to integrate complementary approaches with a strong evidence base into clinical and community settings.