Panel Discussion: Current Directions in Integrative Medicine and Integrative Health

National Advisory Council for Complementary and Integrative Health (NACCIH) Meeting

February 3, 2017

Dr. Josephine Briggs, Director of the National Center for Complementary and Integrative Health (NCCIH), introduced a panel discussion featuring:

• Dr. Ralph Snyderman, Chancellor Emeritus and James B. Duke Professor of Medicine at Duke University (participating by WebEx)
• Dr. Janet Kahn, Research Assistant Professor at The University of Vermont’s College of Medicine
• Council member Dr. Eric Schoomaker, Professor and Vice Chair for Leadership, Centers and Programs, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences.

Dr. Briggs introduced the discussion by observing that in light of NCCIH’s name change in December 2014, it seemed timely to discuss what we mean by “integrative health.” She pointed out that these phrases—integrative health or health care, integrative medicine—are part of an active public dialogue about health care, and that a recurrent concern in that conversation is the need for greater patient centeredness and participant engagement. NCCIH may be able to further this dialogue through its research investments. She indicated that she was eager for advice and input from the panel and the Advisory Council on the research implications of the current dialogue about integrative health care.

Presentation by Dr. Snyderman

Dr. Snyderman observed that NCCIH’s adoption of a name that includes “integrative” was a positive development. With its new integrative focus, NCCIH could become involved in issues critical to health care in this country.

The chronic diseases that are today’s most important health challenges develop slowly and are subclinical during most of their evolution. The current health care system focuses primarily on the management of established clinical disease, but new technology is allowing us to detect disease earlier and to use genomics and other predictive technologies to determine baseline risk. It is now possible to focus on health enhancement and disease risk reduction for people who are not yet ill, as well as optimizing treatment for those who are ill through precise care.

However, there are challenges in the relationship between technology and the role of individuals in their own care. For most diseases, risk is heavily dependent on what the individual does—nutrition, substance exposure or avoidance, physical activity, stress, and the psychosocial environment. The difficulties in linking individual behavior to medical technologies and capabilities may provide research opportunities for NCCIH.

The Wheel of Health, developed under the leadership of Dr. Tracy Gaudet when she was at Duke University, emphasizes that individuals, and their relationship to other factors in their lives, are at the center of their own health care. The Wheel of Health has informed the development of personalized health plans, now in use at Duke and at the Department of Veterans Affairs (VA), and soon to be in use at a federally qualified health center in Durham, North Carolina. This approach includes:

• Enhancing patient engagement
• Assessing the patient’s current health
• Assessing the patient’s health risks
• Developing—in partnership with the patient—a therapeutic/wellness plan and shared health goals
• Tracking metrics
• Working with the patient to provide support and coordination to help meet the shared goals.

The other institutes and centers (ICs) at the National Institutes of Health (NIH) are not focusing on this holistic, patient-centered approach to health, so NCCIH can make unique contributions.

Dr. Snyderman suggested the following possible areas of research focus:

• Metrics for quantification of health engagement
• Methods to enhance awareness and engagement
• Identification of the best approaches to maintain engagement and adherence
• Identification of the best complementary approaches to support therapeutic and wellness plans.

Presentation by Dr. Kahn

Dr. Kahn congratulated NCCIH on having “health” in its new name—something few ICs have—but regretted that there wasn’t room to also include “care.” She noted that while many things these days call our attention to the illness end of an illness–wellness spectrum, NCCIH will need to claim its full territory on this continuum and may be particularly able to contribute to understanding of how to create wellness.

At some level, there has always been “integration” in health care, with the patient doing the integration by bringing information from one provider to another. However, traditionally, providers rarely communicated with one another directly. As medicine moves toward a more truly integrated team approach, it is important to consider two values that have been hallmarks of the integrative health care movement and that we still have much to learn about:

• The first is that it is patient-centered or patient-driven. This means at least that the patient is part of the team and that the patient’s goals and circumstances are key in setting the direction of the care. This is best exemplified by the work Dr. Gaudet and others are doing in the VA and that Dr. Snyderman has described so well. We need to learn what patients need in order to use the position and power they are being offered in this model. And we need to learn how to spread this model faster. What facilitates this at the level of institutional policies and structure? What interferes with it?
• The second value is teamwork: how to develop teams and work effectively in teams. The patient should be part of the team, but there’s also a need to purposefully develop teamwork among health care providers, even if the team is geographically dispersed (as with telemedicine).

New developments in medical education, such as The University of Vermont’s movement toward a lecture-free medical school in which students spend the bulk of their “classroom” time problem-solving in teams, may help to prepare physicians to work in teams. However, those classroom teams will likely not include other types of health professionals, and medical school curricula are lacking in integrative health content and contact at this time.

Priority issues for the coming years include:

• Addiction to opioid analgesics. The potential value of integrative approaches in addressing this problem needs to be investigated in connection with:
  • Pain management (including strategies to reduce the risk of addiction)
  • Acute withdrawal and the early phases of addiction treatment
  • Helping patients learn to live a healthy, satisfying, addiction-free life.
• Deaths from medical errors: This is now the third highest cause of death in the United States. In 2015 it was 10 times the number dying from heroin, cocaine, and/or opioid analgesics.
• The high levels of stress and burnout experienced by health care providers. These are a concern in and of themselves, and are a likely factor in the medical error rate. Self-care is a strong tenet of integrative nursing but practice does not meet theory often enough. Dr. Kahn suggested solutions may lie in organizational structure, priorities, and policies, and this may be a worthy line of investigation.

Dr. Kahn described a project she has been involved with, called Mission Reconnect, that uses an app to provide military personnel and their partners with instruction in 12 mind and body practices. It was designed for use during the challenging period after the end of a deployment. Testing of Mission Reconnect showed that people are willing to use the app (the mean number of uses was 20/week in the first 8 weeks for a total of 2.5 hours of use, with a modest decline by week 16), can learn practices taught in this way, and find them helpful. Significant improvements were seen at 8 and 16 weeks in measures of post-traumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to the Mission Reconnect arms of the trial. Dr. Kahn hypothesized that the relatively high use may reflect patient satisfaction with the level of control they have with this kind of program.

Electronic tools like Mission Reconnect may enable some types of patient-driven care to be provided inexpensively.

Presentation by Dr. Schoomaker

Dr. Schoomaker focused on chronic pain and comorbid conditions, especially as experienced by military personnel, their family members who are eligible for care, and veterans. (In the aggregate, the Military Health System [MHS] comprises 9.6 million eligible beneficiaries of health care; the VA has approximately the same number of beneficiaries.) Recent military conflicts have involved the extensive use of explosives, placing everyone in the environment at risk—including those in roles not traditionally considered combat roles, such as cooks and truck drivers. The stresses that military personnel face are not just physical; they include psychological stresses such as those resulting from the loss of fellows and separation from their families.

Dr. Schoomaker showed the trailer from the 2012 documentary Escape Fire, which highlights some of the problems faced by the current health care system.

In the military and veterans’ health care systems, integration does not mean abandoning conventional practices. Rather, it means implementing complementary practices that have evidence of effectiveness as part of the conventional system. As new practices emerge, the system will be receptive because a framework exists for integrating them.

The military has seen sharp increases in musculoskeletal and mental disorders in recent years, without similar increases in other health problems. Wounded, injured, and ill personnel and family members may receive multiple prescriptions for opioids and other medications as they move through the health care system and go from place to place for treatment. The military recognized in 2007 that opioid overdoses are a significant problem, and they’re still an important issue today.

Multiple health problems—chronic pain, post-traumatic stress disorder, and traumatic brain injury—typically occur together in military personnel and veterans. It’s rare for any of these conditions to exist alone. Complementary or nonpharmacologic approaches to the pain component are rarely tried unless nothing else has worked. Often, nonpharmacologic approaches are expected to overcome years of attempts to treat chronic pain with drugs, which may not be realistic.

Federal agencies have supported initiatives related to pain management, with the first steps coming from the VA, with its Pain Program Office, and the Department of Defense (DoD), with its Pain Management Task Force. Further efforts have included the Institute of Medicine’s “Relieving Pain in America” report and steps to implement its recommendations through the National Pain Strategy. In the meantime, the MHS has been reviewed, and NCCIH has worked with the DoD and VA to develop collaborative research efforts. The most recent developments include a 2015 presidential memorandum on drug abuse, the 2016 Comprehensive Addiction and Recovery Act, and the Centers for Disease Control and Prevention’s 2016 opioid prescribing guidelines.

Dr. Schoomaker showed the Samueli Institute’s model for improvement of outcomes in chronic pain, which has four central features:

• Integrative care delivery (how to truly integrate all complementary and conventional practices)
• Patient self-efficacy (including engagement of both patients and patient advocates)
• Operations that support (i.e., support for improved outcomes at multiple levels of leadership)
• Sustainable business model (an essential element for successfully addressing the problem of chronic pain).

Work is still needed in all four areas.

Discussion

Dr. Briggs thanked the presenters and asked Dr. Gaudet, who was participating by telephone, to comment. Dr. Gaudet explained that recent legislation, the Comprehensive Addiction and Recovery Act, enables the VA to develop 15 demonstration sites in fiscal year 2018 to assess the feasibility of an integrative approach to pain management and related health care services. The legislation will allow the VA to capture more consistent metrics and develop a more unified approach to care.

Dr. Briggs said that the presentations made here serve as reminders of the magnitude of the problems the health care system faces. For NCCIH as a research support organization, the topics addressed may provide insights into opportunities for systems investigations into what works and what doesn’t. The NIH Health Care Systems Research Collaboratory has been using a model in which pragmatic clinical trials are conducted within health care delivery systems. This model is cost-effective because the health care system is a partner, for example often paying some of the costs of the intervention, with NIH paying for the research cost. Conducting studies in this way is feasible but challenging.

Council member Dr. Lynn DeBar, Senior Investigator at the Kaiser Permanente Center for Health Research in Portland, Oregon, pointed out that the participants in trials of integrative approaches are often people who have already had multiple treatment failures. Research may be more productive if patients can be seen earlier. Although primary care providers are enthusiastic about integrative care, they also need much education. Communications need to be crafted thoughtfully to avoid reinforcing the idea of a mind-body split (i.e., if pain is real, it should be treated by surgery). Support from the health care system is essential to success.

Dr. Briggs noted that grant applications that compare drug and nondrug approaches are rare. In the real world, people with chronic pain generally need more than one approach, and their treatment includes drug therapy. Another area that is problematic right now is distinguishing chronic pain and the comorbidity of addiction and the caution of health care providers in addressing addiction issues.

Dr. Schoomaker noted that military personnel are often very receptive to complementary approaches, perhaps because of exposure to non-Western cultures. However, providers may not have the resources to use these approaches. Efficacy and effectiveness are still guiding principles for choosing what approaches to offer; patients need to know that the approaches are effective, and providers may become more convinced of their effectiveness after they see them in use.

In response to a question from Dr. Briggs about bringing integrative approaches to the leading edge of health care delivery, Dr. Snyderman explained that progress has been disappointing in most areas, but the VA is an exception. The VA, which is self-insured, has been a leader in care redesign. Hopefully, its holistic approach to care will show intrinsic cost benefits and demonstrate that things can be done in a better way. Outside the VA system, however, current approaches to reimbursement can be a major obstacle.

Dr. Snyderman also noted that the ability of integrative approaches to empower patients may be important in improving quality of life regardless of whether the approaches change disease biology. Enhancing understanding of what empowers people to be active in their care is a research opportunity for NCCIH. Post-meeting, Council member Dr. Cynthia Price, Research Associate Professor of Biobehavioral Nursing and Health Systems at the University of Washington, commented that preventive health care activities could be a greater focus for NCCIH.

Becoming more predictive is an important goal, Dr. Schoomaker explained. For example, it would be valuable to know who’s going to benefit from an intervention such as acupuncture. Dr. Schoomaker also noted that the military is particularly concerned about its investment in health care because dollars spent here cannot be spent to help the military achieve other goals, and because the ultimate goal of military health care is to keep people capable of doing their jobs. In some respect, the military is an excellent venue for promoting these modalities—as the focus is on the readiness of the force to defend the Nation by keeping personnel healthy, functional, and fully capable, not solely on repairing or restoring those who are wounded, ill, or injured in the course of service.

Post-meeting, Council member Dr. Bin He, Distinguished McKnight University Professor in the Department of Biomedical Engineering, University of Minnesota, noted that new neurotechnologies are being developed that are aimed at noninvasively quantifying and intervening with pain. Promising results have been reported on pain quantification, and further research using neuromodulation may potentially bring to the table integrative approaches for pain management.

Dr. Briggs closed the discussion by thanking the participants for their thoughtful comments. She drew attention to two key takeaways:

• The value of NCCIH’s partnership with the DoD and VA—two systems where there are incentives for prevention and early intervention that may be absent elsewhere. It may be possible to demonstrate effects in these systems that would be more difficult to examine in other settings.
• The importance of measuring engagement. Approaches like those used in the Patient-Reported Outcomes Measurement Information System (PROMIS) could capture this, perhaps using smartphones. With tools of this type, it would be possible to effectively study ways in which patients’ expectations, provider characteristics, and other variables influence engagement.