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From the Townsend Letter
November 2016

Sniffing Out Pain
Part 1: Olfaction's Complex Connections of Emotions, Memory, and Pain Perception
by Sarah A. LoBisco, ND
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Part 2 of this article is online

Page 1, 2, 3, 4

An Overview of the State of Chronic Pain in Health Care
In 2011, there were an estimated 100 billion Americans struggling with pain. This outnumbers the estimated 25.8 million with diabetes, 16.3 million with coronary artery disease, 7 million with stroke, and 11.9 million with cancer.
Chronic pain and its consequences are far reaching beyond physical discomfort. According to the American Academy of Pain Medicine's web page Facts and Figures on Pain, there are negative impacts on emotions, quality of life, finances, coping mechanisms (i.e., addiction), and work productivity in those who find no relief for their lasting discomfort.1 These consequences not only affect the individual but also have societal implications through a change in the relationships of the sufferer and the economic burden on health care of the nation.
According to the Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education, the monetary burden is high and the probability of effective treatment to meet an individual's needs is poor:

The annual national economic cost associated with chronic pain is estimated to be $560-635 billion. Pain is a uniquely individual and subjective experience that depends on a variety of biological, psychological, and social factors, and different population groups experience pain differentially. For many patients, treatment of pain is inadequate not just because of uncertain diagnoses and societal stigma, but also because of shortcomings in the availability of effective treatments and inadequate patient and clinician knowledge about the best ways to manage pain. Some answers will come from exciting new research opportunities, but changes in the care system also will be needed in order for patients' pain journeys to be shorter and more successful. In the committee's view, addressing the nation's enormous burden of pain will require a cultural transformation in the way pain is understood, assessed, and treated. This report provides recommendations intended to help achieve this transformation.2

Unfortunately, our current management of pain suppression with commonly prescribed opioid medications is not only inadequate, but also creating an epidemic of addiction and overuse.2
According to the National Institute of Health's National Institute on Alcohol Abuse and Alcoholism, there was a doubling of nonmedical use of prescription opioids in the US from 2001 –2002 (1.8%) to 2012–2013 (4.1%). This means that from 2012 to 2013, approximately 10 million Americans took opioid medications without a prescription or not as prescribed (i.e., more often, a greater amount, or for an increased duration).3 Furthermore, over 11% of the population reported nonmedical use of opioids during their lifespan.4
Regarding American's addiction to opioids, a 2014 Senate Caucus on International Narcotics Control stated:

Several factors are likely to have contributed to the severity of the current drug abuse problem. They include drastic increases in the number of prescriptions written and dispensed, greater social acceptability for using medications for different purposes, and aggressive marketing by pharmaceutical companies. These factors together have helped create the broad "environmental availability" of prescription medications in general and opioid analgesics in particular.

As alarming and baffling as the rising prescribing of an insufficient health-care intervention is, so is the risk of harm that accompanies it. Recently, a 2016 study in JAMA reported that for patients with noncancer pain, prescriptions of long-acting opioids were associated with higher rates of mortality as compared with alternatives to opioids (e.g., anticonvulsants and antidepressants).6,7 According to the study, "The HR during the first 30 days of therapy (53 long-acting opioid, 13 control deaths) was 4.16 (95% CI, 2.277.63) with a risk difference of 200 excess deaths (95% CI, 80-420) per 10 000 person-years."6
The pricelessness for finding an alternative to these risky medications is evident and imperative. A 2011 press release by Global Industry Analysts Inc. stated:

Higher demand for more efficient drugs and medical device for pain treatment continue to drive the pain management market. Currently, more than 1.5 billion people worldwide suffer from chronic pain of varying degrees. Of all types of chronic pains, neuropathic pain stands as the highly underserved market…With increasing aged population and absence of a full-fledged pain management therapy, demand for better pain management therapies, addressing acute and chronic pain, is on the rise.8

The federal government has taken heed. On March 18, 2016, the Office of the Assistant Secretary for Health at the US Department of Health and Human Services released its first coordinated National Pain Strategy.9 It provided an outline of the federal government's plan for lowering the drain of chronic pain on millions of Americans.9,10 The strategy was a response to 2011 call from the Institute of Medicine (IOM; now renamed the National Academy of Medicine) for "a coordinated, national effort of public and private organizations to transform how the nation understands and approaches pain management and prevention."9-11 As a result, the US Department of Health and Human Services appointed the task to a group of representatives of scientists, researchers, federal agencies, and the public. The four key areas of focus were reported as follows:

  • developing methods and metrics to monitor and improve the prevention and management of pain;
  • supporting the development of a system of patient-centered integrated pain management practices based on a biopsychosocial model of care that enables providers and patients to access the full spectrum of pain treatment options;
  • taking steps to reduce barriers to pain care and improve the quality of pain care for vulnerable, stigmatized, and underserved populations;
  • increasing public awareness of pain, increasing patient knowledge of treatment options and risks, and helping to develop a better informed health care workforce with regard to pain management.9

One definition of insanity, poignantly referenced in addiction-recovery circles, is: doing the same thing over and over and expecting different results. Thankfully, the public, government, and medical professionals all agree that our current approach in addressing pain is lacking a sane and scientific foundation. We need a more rational tactic for alleviating millions of Americans' chronic and debilitating discomfort. As integrative practitioners are well known for efficacy in lifestyle medicine, one would expect more acceptance of them woven into this new method, especially considering that the National Pain Strategy specifically highlights "patient-centered integrated pain management practices."9,12-15  However, "a biopsychosocial model of care that enables providers and patients to access the full spectrum of pain treatment options" isn't as inclusive as one would expect.9 This is for several reasons.
A 2015 small review of outpatient integrative health-care facilities' clinical trials made evident that the integrative health-care model presents a challenge for equal comparison with our current evidence-based outcome trials.12 Whereas conventional treatment is largely focused on a single intervention, integrative practitioners provide complex and multipronged plans. This makes direct causal evaluations difficult and hard to extrapolate for those schooled solely in the more conventional model. Furthermore, some of the principles of integrative care are not objective markers that can easily be validated, valued, and understood. For example, the evaluation of the impact of the therapeutic relationship and the role of patient empowerment on pain is not easily converted to a drug or surgical effect on objective clinical end points in evidence-based approaches.
Still, evidence is emerging for this cohesive approach into the current system. As stated in a 2015 booklet by the Integrative Healthcare Policy Consortium, integrative health care has been shown to be a promising cure for excessive health spending with poor results in all areas of health, including chronic pain. It states the following regarding chiropractic care for low back pain:

A 2010 study was designed to determine if there are differences in the costs of low back pain care when a patient is able to choose treatment from a medical doctor (MD) versus a doctor of chiropractic (DC). 50 Researchers analyzed data from 85,000 Blue Cross Blue Shield (BCBS) beneficiaries in Tennessee over a two-year span in which patients had equal access and insurance coverage to the MDs and DCs.

The study found that costs for care initiated with a DC were almost 40% less than the care initiated with an MD. Even after risk-adjustment, episodes of care initiated with a DC were 20% less expensive. Routine use of DCs as the initial provider for low back pain would potentially lead to annual cost savings of $2.3 million for BCBS of Tennessee. The researchers also concluded that insurance companies that restrict access to chiropractic care for low back pain treatment may inadvertently pay more for care than they would if they removed such restriction.13

Furthermore, a 2008 randomized, control trial of an economic evaluation of naturopathic medicine in chronic low back pain found that naturopathic care was a more cost-effective treatment than a standardized physiotherapy education regime.14
Unfortunately, even with our current need for a new approach, and trials showing efficacy of integrative practitioner approaches, availability to holistic approaches for pain management in our nation is not easily accessible.15 One reason maybe the fact that, whereas the original Interagency Pain Research Coordinating Committee included a naturopathic doctor (ND) and an integrative conventional medical doctor (MD), there was an absence of their professional representation in the oversight panel for forming the strategy.15-17 The resultant strategy has "left the door open," according to review in Huffington Post from respected integrative columnist John Weeks; but, as one pores through the 84-page document, nudging open this door with honorable mentions may be challenging.10,15 Still, the value of a governmental recognition that a more expansive viewpoint that includes practitioner cohesion for effective patient-centered care is needed provides a good start.
In this two-part article, I will set the basis to review a modality that could perhaps be the most clinically integrative tool used by all practitioners for pain. It has already been extensively studied, and by its very nature is comprehensive and holistic. Furthermore, it is low cost and does not require complicated strategies for implementation or expensive, time-consuming, planning teams. Specifically, I will be discussing using the power of smell and the application of essential oils to modulate the perception, pathways, and healing of chronic pain.
In this article, I'll explore the physiology of smell, including how it affects emotions and memories, and how this relates to pain processing. In this way, I will demonstrate the sole power of olfaction alone in pain relief with its resultant ripple effects on emotions of the individual and through societal and relationship outcomes. In a future article, I will explore studies on the mechanisms and clinical trials of using essential oils for patients suffering from chronic pain and discomfort. Essential oils provide relief of pain in addition to olfactory responses, as these secondary metabolites modulate physiology, biochemistry, and psychology through various mechanisms beyond their aroma.18-24

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