At University of Washington's Harborview Medical Center, the Seattle region's only Level I Trauma and Burn Center, the demands for in-patient care are dramatically different from a private clinic environment. The Acute Pain Service at Harborview estimates having approximately 7,000 encounters each year, and of those, 70 percent have a substance abuse diagnosis. Aside from trauma, addiction, and polypharmacy, many of the patients are also struggling with post-surgical pain management, abscesses, and other necrotizing soft-tissue infections (NSTI).
The Collaboration
Bastyr University's Doctorate of Acupuncture and Oriental Medicine program has collaborated with the University of Washington's Harborview Medical Center to provide a unique clinical rotation to address these conditions. The current iteration of Bastyr's DAOM program is focused on advanced pain management with a strong emphasis on research and biomedicine including neurobiology, low level laser therapy and electroacupuncture, pharmacology, and a plethora of other pain alleviation techniques within the scope of acupuncture medicine. These enable acupuncturists skilled in sophisticated traditional diagnostics to use scientifically validated tools in a hospital setting.
According to Dr. Ivan Lesnik, the head of the Anesthesiology and Pain Medicine Department at Harborview, and medical acupuncturist, "The clinical partnership between Harborview and Bastyr brings many benefits, most notable the benefit to patients struggling with pain, and the opportunity for multiple disciplines to work together collaboratively in meeting the needs of hospitalized patients."
Pain Management in a Hospital Setting
Bastyr's doctoral cohorts provide care within the Anesthesiology and Pain Medicine Department at Harborview twice a week. DAOM students learn hospital infectious control procedures, reading and charting with electronic health records, and work alongside nursing staff, physicians, and patients.
A Bastyr doctoral candidate's day starts with a round table with residents and an integrated team of substance abuse specialists, pharmacists, nurses, and psychologists where a list of inpatients is triaged for treatments including acupuncture. Subsequently, the DAOM interns contact the patients to determine if they'd like to receive acupuncture, often educating them about its risks and benefits.
DAOM interns ask patients relevant questions to determine an acupuncture diagnosis, chart their pain levels using the Visual Analog Scale (VAS), and establish their chief complaint and primary objective for treatment. Pain measures are quantified to track effectiveness in large populations as well as for the person in the hospital bed. Longer term health goals may also be discussed during or post treatment since these are consonant with acupuncture as a holistic medicine.
The Value of Interns
The DAOM interns use standard hospital precautions including plastic gowns for patients in enteric isolation, and needle with gloves on as part of their safe contact. Depending on the patient's diagnosis, position, and pathology, an appropriate set of acupuncture points are identified with most patients receiving a combination of auricular, manual, and electroacupuncture. Post-treatment pain levels are recorded and the acupuncturist documents guidelines before exiting the patient room.
The doctoral student acupuncturists have learned to quickly adjust treatment plans to a patient's immediate needs. There have also been memorable moments when making friendly connections with staff or consulting with doctors and nurses on the benefits of acupuncture before or after surgery. Dr. Lesnik reported, "Working with the advanced acupuncture students in the integrative setting here at Harborview hospital has been enriching for both staff and patients in directly supporting provision of ideal patient centered care."
Even more memorable were times when patients in severe (10 out of 10) pain quickly fell asleep after just a few well-placed needles.
Policy and the Opioid Crisis, and Where We Come In
Bastyr's efforts at Harborview have been well received. "The benefit I've seen them bring to patients suffering from high levels of pain is in the ability to provide relief without the burden of the side effects often associated with pain medications," writes Dr. Lesnik.
Harborview is doing a quantitative study on the data produced from its collaboration with Bastyr's DAOM program. Besides the positive anecdotal responses from patients and staff, the data is producing a normative bell-shaped curve in pain relief. Quantitative findings such as these drive acceptance of acupuncture as a viable treatment for pain in standard medical facilities and for consideration by policymakers.
The Center for Disease Control (CDC) acknowledges that chronic pain is a multidimensional and individualized health concern which must be addressed in novel ways by both patients and providers. Insurance companies are increasingly covering acupuncture as they listen to their subscribers and train physicians to start talking with their patients about non-drug interventions. As of January 2018, the Joint Commission which accredits more than 21,000 U.S. health care organizations has instructed their 3,000 hospitals to provide non-pharmacologic pain options.
Prescribed Opioids and Improving Legislation
Almost half of the opioid overdose deaths in the U.S. involve a prescribed opiate. The sales of prescribed opiates and subsequent deaths have tripled since 1999. Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999. Since 2009, drug overdose deaths have outpaced traffic accidents as the leading cause of injury death in the United States and in 2016 more people died from an overdose than in all of the years of the Vietnam War.
In "Blueprint for Prescriber Education for Extended-Release and Long Acting Opioids," published by the U.S. FDA in 2017, medical doctors were challenged to be well informed on prevention and/or treatment of pain using non-pharmacological modalities. By July, The National Academies of Science, Engineering, and Medicine (NASEM) accelerated a "culture change" in pain management by requesting more education on non-opioid relief in order to reduce the demand and harm of opioid abuse.
Recently the Washington state professional body WEAMA (Washington East Asian Medicine Association) successfully petitioned the governor for inclusion on legislation to address the opioid crisis, HB 2489. Although this legislation did not pass during the 2018 legislative session, rulemaking for a prior bill ESHB 1427 is still underway. The current draft language calls for the practitioner to consider non-pharmacologic therapy, including acupuncture, rather than defaulting to the use of opioid therapy alone whenever reasonable, evidence based, and clinically appropriate alternatives exist.
By expanding our roles as TCM practitioners, acupuncturists can bring potentially far-reaching change to conventional patient care. Due to the strong curriculum in biomedicine, research, and written communication, Bastyr DAOM students are able to soundly advocate for acupuncture as an evidence-based medicine to the Western medical community. It has been inspiring to see the benefits of acupuncture for in-patient care at Harborview, and to work with staff and administration to create a model which may be used in other facilities.
References
Structured water (H3O2) can be considered a fourth state of water between liquid and solid. It has the hexagonal structure of ice; however, missing a critical bond, it behaves more like a gel than a solid, but retains some of its crystalline structure.
In the past five years of my clinical practice, I have seen an astonishing upsurge in the chronic use of proton-pump inhibitor (PPI) medications for the gastrointestinal issue diagnosed by allopathic medicine as GERD. It is not uncommon to encounter patients taking these prescriptions for five-plus years.
Working with chronically ill patients entails acknowledging the reality that not all patients will survive their diagnosis. Chinese medicine and acupuncture play a crucial role in palliative and end-of-life care, addressing medication and disease side effects, alleviating pain associated with death, reducing anxiety and stress, and helping patients find peace during the dying process.
