Transcript Slide 1

Naturopathic Management
of Chronic Pain in the
Older Adult
Diana Quinn, ND
Hygeia Center for Healing Arts
Beaumont Hospital Integrative Medicine
Naturopathic Medicine
• Licensed Naturopathic doctors (NDs) are general
practitioners with a specialty in natural medicine.
• Pre-med undergraduate degree, four years at
nationally accredited naturopathic medical school,
pass North American licensing exams (NPLEX)
• NDs specialize in evidence-based complementary
and alternative medicine (EBCAM).
Naturopathic Medical Schools
in North America
Naturopathic Medical
Education
• Basic Sciences
• Organ Systems
• Clinical Training
• Naturopathic Modalities
Naturopathic Modalities
• Clinical Nutrition
• Botanical Medicine
• Homeopathy
• Hydrotherapy
• Physical Medicine
• Lifestyle Counseling and Stress Management
• Chinese Medicine, Acupuncture
Naturopathic Philosophy
• The Healing Power of Nature
• Identify and Treat the Cause
• Treat the Whole Person
• First Do No Harm
• Doctor as Teacher
• Prevention
Who Uses CAM?
• Between 42%- 68% of Americans are using some
form of complementary and alternative modality as
part of their healthcare.
•
Nahin, RL, Barnes PM, Stussman BJ, and Bloom B. Costs of Complementary and
Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States,
2007. National health statistics reports; no 18. Hyattsville, MD: National Center for Health
Statistics. 2009.
•
Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC.
Trends in alternative medicine use in the United States, 1990–1997 Results of a follow-up
national survey. JAMA. 1998;280(18):1569–1575.
• Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA,
Kaptchuk TJ, Eisenberg DM. Long-term trends in the use of complementary and
alternative medical therapies in the United States. Ann Intern Med. 2001;135(4):262–
268.
CAM Use in Older Adults
• 2007 National Health Interview Survey found that
38% of U.S. adults reported using CAM in the
previous 12 months, with the highest rates among
people aged 50–59 (44%)
• 42 percent of adults who used CAM in the past
12 months disclosed their use of CAM to a
physician (MD or DO)
•
Barnes PM, Bloom B, Nahin R. Complementary and Alternative Medicine Use Among
Adults and Children: United States, 2007. CDC National Health Statistics Reports #12. 2008.
Disclosure of CAM Usage
• AARP & NCCAM Survey Report (2010): telephone
survey of 1000 participants ages 50+:
• Over half surveyed use CAM and over 1/3 take herbal
or nutritional supplements.
• …Yet only a third of patients using CAM disclosed to
their health care provider.
• Complementary and Alternative Medicine: what people aged 50 and older discuss
with their health care providers. NIH National Center for Complementary and
Alternative Medicine, AARP
CAM for Pain Management
• Other studies have found that pain is the primary
reason that older adults seek out CAM therapies
• Astin JA, Pelletier KR, Marie A, Haskell WL. Complementary and alternative
medicine use among elderly persons: One-year analysis of a Blue Shield Medicare supplement. J Gerontol A Biol Sci Med Sci 2000;55:M4–M9.
• Cheung CK, Wyman JF, Halcon LL. Use of complementaryand alternative therapies
in community-dwelling older adults. J Altern Complement Med 2007;13:997–1006.
CAM for Persistent Pain
• Persistent pain is defined as a prolonged experience
of pain that continues for an extended period of
time and may or may not be associated with a welldefined disease.
• Negative outcomes associated with persistent pain
include poor health, depression, cognitive decline,
and higher usage of pharmaceuticals.
• Munk et al. Massage therapy usage and reported health in older adults in experiencing
persistent pain. J Alt Complementary Med 2011;17(7):609-16.
Causes of Persistent Pain
• Musculoskeletal pain
• Osteoarthritis, Rheumatoid Arthritis, Fibromyalgia
• Visceral pain
• Cancer, gastrointestinal disorders, urogenital disorders
• Neuropathic pain
• Herpes zoster, neuralgia, neuropathy, MS
Integrative Therapeutics
for Pain Management
Anti-Inflammatory Agents
Analgesics
Supportive Nutrients
Acupuncture
Massage
Mind/Body Medicine
Natural Anti-Inflammatory
Agents
• Turmeric (Curcuma longa)
• MSM
• Others include Holy Basil (Ocimum sanctum),
Rosemary (Rosmarinus officinalis) and Green Tea
extract (Camellia sinensis)
Turmeric (Curcuma longa)
• Anti-inflammatory through inhibition of LOX and
COX, antihistamine
• Antioxidant and hepatoprotective
• Anti-nociceptive
• Basnet P, Skalko-Basnet N. Curcumin: an anti-inflammatory molecule from a curry
spice on the path to cancer treatment. Molecules 2011, 16, 4567-4598.
• Liju V et al. An evaluation of antioxidant, anti-inflammatory and antinociceptive
properties of essential oil from Curcuma longa. Indian J Pharmacol. 2011 Sep;43(5):52631.
• Arora RB, Basu N, Kapoor V, Jain AP. Anti-inflammatory studies on Curcuma longa
(turmeric). Ind J Med Res 1971;59:1289–95.
Turmeric (Curcuma longa)
• A preliminary trial in people with RA found
curcumin to be useful for reducing inflammation,
pain and stiffness.
• Deodhar SD, Sethi R, Srimal RC. Preliminary studies on antirheumatic activity of
curcumin (diferuloyl methane). Ind J Med Res 1980;71:632–4.
• In a blinded studay, curcumin was superior to
placebo or phenylbutazone (an NSAID) for
alleviating post-surgical inflammation.
• Satoskar RR, Shah SJ, Shenoy SG. Evaluation of anti-inflammatory property of
curcumin (diferuloyl methane) in patients with postoperative inflammation.Int J
Clin Pharmacol Ther Toxicol 1986;24:651–4.
Turmeric (Curcuma longa)
• Contraindications
• Pregnancy, gallbladder disease
• Adverse effects
• None documented
• Drug interactions
• May inhibit CYP3A4 drug clearance
• Supplementation considerations
• Poorly absorbed in whole form, quality of supplement
imperative for efficacy
• Dosage of standardized 90% extract 375-500 mg TID
Methylsulfonylmethane
(MSM)
• Organosulfur molecule that can be synthesized
commercially from dimethylsulfoxide (DMSO).
• Anti-oxidant, chemoprotective properties, antiatherosclerotic action.
• RCT of 49 subjects aged 49-90 received either 1.125
g TID or placebo. After 12 weeks, total symptoms
decreased in treatment group by 20% and increased
in placebo group by 14%.
• Debbi et al. Efficacy of methylsulfonylmethane supplementation on osteoarthritis of
the knee: a randomized controlled study. BMC Complementary and Alternative Medicine
2011, June 11:50
Methylsulfonylmethane
(MSM)
• Contraindications
• None documented
• Adverse effects
• Rare diarrhea, rash, headache reported
• Drug interactions
• None documented
• Supplement considerations
• Dosage
Botanical Analgesics
• A Cochrane Review published in 2007 found ten trials
of herbal analgesics Devil’s Claw Harpagophytum
procumbens), White Willow Bark (Salix alba) and
Cayenne pepper (Capsicum frutenscens) were found to
reduce pain more than placebo.
•
Gagnier J et al. Herbal Medicine for Low Back Pain: A Cochrane Review. Spine. 32(1):82-92,
January 1, 2007.
Devil’s Claw
(Harpagophytum procumbens)
• Has a broader mechanism of
action than NSAIDs by
interacting with both COX- and
LOX-mediated pathways of the
arachidonic acid cascade as well
as with the release of cytokines
• Loew D et al. Investigations on the pharmacokinetic
pro- perties of Harpagophytum extracts and their
effects on eicosanoid biosynthesis in vitro and ex
vivo. Clin Pharmacol Ther 2001;69:356–64.
•
Fiebich B et al. Inhibition of TNFa synthesis in
LPS-stimulated primary human monocytes by
Harpagophytum extract. Phytomedicine 2001;8:28–30.
Devil’s Claw
(Harpagophytum procumbens)
• In subjects taking 50 mg of Devil’s Claw, the
percentage with no pain or mild pain increased over
the 4-week period (from 2% in week 1 to 24% in
week 4), whereas the percentage with unbearable or
severe pain decreased over the 4 weeks (from 59% in
week 1 to 35% in week 4).
• Chrubasik S, Junck H, Breitschwerdt H, et al. Effectiveness of Harpagophytum
extractWS1531 in the treatment of exacerbation of low back pain: a randomized,
placebo-controlled, double blind study. Eur J Anaesthesiol 1999;16:118–29.
Devil’s Claw
(Harpagophytum procumbens)
• RCT of 88 patients aged 45-72 having chronic LBP
were randomized to receive either 2400 mg of the
active compound harpagoside plus placebo, or 12.5
mg tablet of Vioxx plus placebo.
• 79 subjects completed the study with 20% of patients
receiving Devil’s Claw pain-free and 10% reofecoxib
pain-free.
• Chrubasik S et al. A randomized double-blind pilot study comparing Doloteffin and
Vioxx in the treatment of low back pain. Rheumatology 2003;42:141–148
Devil’s Claw
(Harpagophytum procumbens)
• Of the original 88 patients in previous study, 53
patients remained in a one-year follow-up.
• At 24, 43 and 54 weeks there continued to be no
difference between treatment with Devil’s Claw and
rofecoxib on Arhus Index and health assessment
questionnaire scores (HAQ)
• Long-term treatment with Devil’s Claw was effective
and well tolerated.
• Chrubasik S et al. A 1-year follow-up after a pilot with Doloteffin for pain.
Phytomedicine. 2005 Jan;12(1-2):1-9.
Devil’s Claw
(Harpagophytum procumbens)
• Contraindications
• Cardiovascular disease, patients taking warfarin
• Adverse reactions
• Dyspepsia – increases stomach acid production
• Drug interactions
• Medications cleared by the liver via CYP450 2C19, H2
blockers, PPIs
• Supplement considerations
• Dosage 2400 mg BID
White Willow Bark (Salix alba)
• Contains salicin
• Anti-inflammatory and
anodyne
• Slow-acting and long-lasting
pain relief
White Willow Bark (Salix alba)
• A total of 228 subjects were given a daily dose of 240 mg
salicin against 12.5 mg per day of rofecoxib in a 4-week trial.
• Both the rofecoxib and the salicin groups improved on the pain
scale (by 44% in both groups), the Arhus scale invalidity index,
pain index, and physical impairment index.
• The percentage of patients requiring NSAIDs and/or tramadol
was 10% for the S. alba group and 13% for the rofecoxib group.
• … there are no differences in effectiveness between a 240-mg
salicin dose of an extract of S. alba and 12.5-mg rofecoxib per
day in treatment of acute episodes of chronic pain
White Willow Bark (Salix alba)
• 4-week RCT of 210 subjects tested two doses of S. alba,
standardized to either 120 mg or 240 mg salicin per day,
against placebo.
• In the 4th week, greater number of subjects with pain-free
days in treatment groups than placebo.
• 120 mg salicin dose of an extract of S. alba was more
effective in relieving pain than placebo, with the effect
being dose-dependent and greater at 240 mg.
• Chrubasik S, Eisenberg E, Balan E, et al. Treatment of low back pain exacerbations
with willow bark extract: a randomized double-blind study. Am J Med 2000;109:9–14.
White Willow Bark (Salix alba)
• Total of 261 patients in two studies demonstrated an
increased number of pain-free patients, decreased
number of patients requiring relief medication, and
improved Arhus index scores.
• Significant differences between the 120 mg and 240
mg groups, demonstrating that 240 mg reduces pain
more than placebo and 120 mg dose of S. alba.
• Chrubasik S, Kunzel O, Model A, et al. Treatment of low back pain
with a herbal or synthetic anti-rheumatic: a randomized controlled
study. Willow bark extract for low back pain. Rheumatology
2001;40:1388–93.
White Willow Bark (Salix alba)
• Contraindications
• Pregnancy and breastfeeding, patients with gastritis or ulcers,
children
• Adverse effects
• Stomach upset, tinnitus at high doses
• Drug interactions
• Anticoagulants, beta blockers, diuretics, methotrexate and
phenytoin
• Supplement consideration
• Dosage 60, 120 or 240 mg QD
Cayenne (Capsicum frutescens)
• Topical preparations containing 0.025% to 75% of
capsaicin are applied TID-QID.
• The mechanism of C. frutescens is partially related to
its ability to deplete substance P.
• Numerous double-blind trials have proven C.
frutenscens to be effective for both musculoskeletal
and neuropathic pain.
Cayenne (Capsicum frutescens)
• In a recent RCT, 130 patients with severe
fibromyalgia were randomized to receive 0.075 %
capsaicin cream three times daily in a 6-week trial.
• While no difference in Visual Analog Scale for pain,
there were significant improvements in myalgic score
and pain threshold in study group.
• Reduced fatigue and depressive symptoms were also
observed in trial group.
• Casanueva et al. Short-term efficacy of topical capsaicin therapy in severely affected
fibromyalgia patients. Rheumatol Int 2012 July (Epub ahead of print)
Cayenne (Capsicum frutescens)
• Contraindications
• None documented
• Adverse effects
• Caution must be used to avoid touching eyes and mucous
membranes
• Drug interactions
• None documented
• Supplement considerations
• Topical preparations range from 0.025%-0.075% capsaicin
Nutrients for Pain Support
• Magnesium
• Vitamin D
• L-DLPA
• D-Ribose
Magnesium citrate
• Persistent pain syndromes that can be improved with
magnesium supplementation include restless legs,
MS, fibromyalgia and migraines.
• Deficiency of magnesium is associated with many
chronic disease states, such as diabetes, chronic
fatigue syndrome and fibromyalgia, hypertension
and arrhythmia.
• Many drugs deplete magnesium, and
supplementation is recommended to replenish.
Magnesium citrate
• 60 patients with fibromyalgia were randomized to
receive either 300 mg magnesium, amytriptiline, or
amitryptaline + magnesium.
• The number of tender points, tender point index,
FIQ and Beck depression scores decreased
significantly with the magnesium citrate treatment.
• Amitryptaline + magnesium was only group
improved on all parameters.
•
Bagis et al. Is magnesium citrate treatment effective on pain, clinical parameters and functional status
in patients with fibromyalgia? Rheumatol Int. 2012 January 22 (Epub ahead of print).
Magnesium citrate
• Contraindications
• Patients with kidney disease
• Adverse effects
• Diarrhea at high doses
• Drug interactions
• Dexamethasone, misoprostol, spironolactone, triamterene
• Supplement considerations
• Magnesium citrate or glycinate are best absorbed forms
Vitamin D
• Vitamin D deficiency and insufficiency is prevalent,
and correlated with many chronic disease states
including diabetes, cancer and cardiovascular
disease.
• Insufficient vitamin D intake exacerbates conditions
causing persistent musculoskeletal pain, such as
osteoarthritis, osteoporosis and fracture, and
fibromyalgia.
Vitamin D
• British study of 2070 adults >65, measurements
included serum 25(OH)D, pain status and covariates
(age, sex, social class, season of examination, use of
vitamin supplements and physical health status).
• Results show that the symptoms of
moderate/extreme pain (present in 53 % of the
sample) were associated with poor vitamin D status,
independent of other covariates.
• Hirani V. Vitamin D status and pain: analysis from the Health Survey for
England among English adults aged 65 and over. Br J Nutr. 2012
Apr;107(7):1080-4.
Vitamin D
• Contraindications
• Hyperparathyroidism, sarcoidosis
• Adverse effects
• Increased thirst, increased urination, kidney stones
• Drug interactions
• Verapamil, warfarin
• Supplement considerations
• Cholecalciferol (D3) is best absorbed form, daily doses range
2000-10,000 IU
D,L-phenylalanine (DLPA)
• Amino acid precursor, can be converted into Ltyrosine and subsequently L-dopa, norepinephrine
and epinephrine.
• Believed to up-regulate the endogenous analgesia
system (EAS).
• Promotes enkaphalin activity by inhibiting
enkephalinase.
D,L-phenylalanine (DLPA)
• Improves mood, may alleviate persistent pain.
• Mixed responses in clinical trials for improvement of
persistent pain, little effect on acute pain.
• Several studies demonstrated that DLPA improved
the efficacy of acupuncture for relief of persistent
pain.
• May improve efficacy of opioid pain medications.
• Russel AL, McCarty MF. DL-phenylalanine markedly potentiates opiate analgesia –
an example of nutrient/pharmaceutical up-regulation of the endogenous analgesia
system. Med Hypotheses. 2000 Oct;55(4)283-8.
D,L-phenylalanine (DLPA)
• Contraindications
• Patients with tardive dyskinesia, PKU
• Adverse effects
• Nausea, dyspepsia, transient headaches
• Drug interactions
• L-dopa, potentiates opioids
• Supplement considerations
• Dosage range from 500-1500 mg
D-Ribose
• A 5-carbon sugar produced in the body from glucose
• Important role in synthesis of RNA, DNA and ATP.
• D-ribose shown to increase cellular energy
production in heart and skeletal muscle, may
improve pain from fibromyalgia.
• Teitelbaum JE, Johnson C, St Cyr J. The use of D-ribose in chronic fatigue syndrome
and fibromyalgia: a pilot study. J Altern Complement Med. 2006 Nov;12(9):857-62.
D-Ribose
• Contraindications
• None known
• Adverse effects
• Greater than 10 g daily may cause diarrhea
• Drug interactions
• None known
• Supplement considerations
• Powdered dose of 5 g BID
Acupuncture
• Acupuncture is thought to directly modulate the
affective-cognitive aspect of pain perception, and
changes in brain function have been observed using
MRI during acupuncture treatment.
• Useful for:
• Neuropathy (diabetic, CIPN)
• Musculoskeletal pain
• Visceral pain in oncology patients
Acupuncture for
Persistent Pain
• A meta-analysis of 29 RCTs with a total of 17,922
found that acupuncture was superior to both sham
and no-acupuncture for the relief of neck and back
pain, shoulder pain, osteoarthritis and headaches.
• Vickers et al. Acupuncture for chronic pain: individual patient data meta-analysis.
Arch Intern Med. 2012 Sep 10:1-10.
Acupuncture in Cancer
• A Cochrane review of trials investigating
acupuncture for pain in cancer patients found only
one high-quality study, which demonstrated that
auricular acupuncture was effective in reducing pain.
• Paley CA, Johnson MI, Tahsani OA, Bagnall AM. Acupuncture for cancer pain in
adults. Cochrane Database Syst Rev. 2011;(1): CD007753.
Massage
• 9 male cancer patients (mean age 56.6 years) who
received two consecutive 30- minute evening massages
reported significant reductions in pain (according to VAS
0–100 mm) as compared to baseline.
• There was a mean reduction in pain, anxiety and
enhanced feelings of relaxation.
• In a case series involving 103 patients with cancer, a
combination of massage and aromatherapy promoted
pain relief in 33% of patients who concluded the study
(47%).
Massage
• In an un- blinded RCT, 28 patients (mean age 61.5
years) with cancer were assigned to either Swedish
massage therapy or a visitor for 10 minutes. Pain
was assessed by a visual analog scale (VAS) from 0
to 10 cm.
• Men experienced immediate pain but this effect
subsided by an hour after the massage. There was no
significant benefit in women, although their baseline level of pain was mild.
Mind-Body Modalities
• Biofeedback
• 15 fibromyalgia patients received 40 biofeedback
treatments and reported reduced stiffness, pain,
tenderness, fatigue and psychological distress.
• 63 patients receiving standard care served as control
and did not experience these improvements.
• Caro XJ, Winter EF. EEG biofeedback treatment improves certain attention and
somatic symptoms in fibromyalgia: a pilot study. Appl Psychophysiol Biofeedback. 2011
Setp;36(3):193-200.
Mind-Body Modalities
• Meditation
• Extensive mental training can result in thickening of cortical
regions associated with pain processing, including
midcingulate cortex (MCC) and primary and secondary
somatosensory cortices.
• Functional imaging demonstrated that during pain,
practitioners had reduced activation in amygdala,
hippocampus, and emotional/evaluative regions of
prefrontal cortex, as well as increased activation in the MCC,
thalamus, and insula.
• Salomons T and Kucyi A. Does meditation reduce pain through a unique neural
mechanism? Journal of Neuroscience, September 7, 2011 31(36):12705–12707.
Mind-Body Modalities
• Mindfulness-based stress reduction is a mind-body
intervention described by Kabat-Zinn.
• The participants met weekly for eight 2.5 hour sessions.
• Mindfulness-based stress reduction may have a positive
impact on mental health in these patients, an effect that
seems to persist after the classes are completed.
• Plews-Ogen et al. A pilot study evaluating mindfulness-based stress reduction and
massage for the management of chronic pain. J Gen Intern Med 2005; 20:1136–1138.
Naturopathic Support for
Side Effects of Pain
Medications
Support for Side Effects of
Pain Medication
• Probiotics
• Magnesium
• Ginger
• Homeopathy
• Acupuncture
Probiotics
• Changes of the gut microflora in the elderly appear
to involve a reduction in numbers of healthy bacteria
(lactobacilli and bifidobacteria) and an increase in
numbers of potentially pathogenic species.
• Older adults have greater susceptibility to
gastroenteritis and functional bowel problems
• Malaguarnera G et al. Probiotics in the gastrointestinal diseases of the elderly. J Nutr
Health Aging. 2012 Apr;16(4):402-10.
Probiotics
• More than 80% of nursing home and extended-care
facility residents are reported to suffer from
constipation.
• This population includes persons with higher
frequency of risk factors: immobility, polypharmacy
including opioid pain medications, and chronic
medical conditions.
Probiotics
• One study of 19 nursing home residents with
chronic constipation found improvement when
supplemented with a probiotic formula of
Lactobacillus acidophilus, Pediococcus pentosaceus, and
Bifidobacterium longum BID x 14 days
•
Subjects’ defecation habit (frequency of defecation,
amount and state of stool) in nursing home residents
with chronic constipation.
• An et al. Efficacy of lactic acid bacteria (LAB) supplement in management of
constipation among nursing home residents. Nutrition Journal 2010, 9:5.
Probiotics
• Contraindications
• Neutropenic patients with WBC <2.5; immune
compromised patients should avoid Sacharomyces boulardii
• Adverse effects
• Rarely gas, bloating, loose stools
• Drug interactions
• None known
• Supplement considerations
• Quality of product is imperative for clinical efficacy
Magnesium oxide
• Osmotic laxative and stool softener
• Doses 500-2500 mg daily for severe constipation
• Magnesium oxide is poorly absorbed, making it the
preferred form of magnesium for laxative effect
Magnesium oxide
• 456 patients were given magnesium prophylaxis for
opioid-induced constipation
• Constipation incidence was 33.7% in treatment
group, and 54.6% in untreated group
• Preventive effect was dose-dependent, requiring
doses over 1000 mg
• Ishihara M et al. A multi-institutional study analyzing effect of prophylactic
medication for prevention of opioid-induced gastrointestinal dysfunction. Clin J Pain.
2012 Jun;28(5):373-81.
Magnesium oxide
• Contraindications
• Patients with kidney disease
• Adverse effects
• Diarrhea at high doses
• Drug interactions
• Dexamethasone, misoprostol, spironolactone, triamterene
• Supplement considerations
• Doses over 1000 mg required to achieve laxative effect as
preventive for opiate-induced constipation
Ginger (Zingiber officinale)
• Preclinical studies have shown that ginger is effective
as an anti-emetic agent and that it possesses 5HT3
antagonistic activity, which is responsible for
reducing chemotherapy-induced nausea and
vomiting.
• Animal studies suggest that ginger is effective in
preventing cisplatin-induced emesis and gastric
emptying.
• Clinical studies have shown that ginger possesses an anti- emetic effect in many
circumstances such as during pregnancy, postoperatively and in motion sickness.
Haniadka R et al. Zingiber officinale (Ginger) as an anti-emetic in cancer
chemotherapy: a review. J Alt Compl Med. 2012;18(5):440-44.
Ginger (Zingiber officinale)
• Contraindications
• Patients on blood thinning medication, before surgery
• Adverse effects
• None known
• Drug interactions
• Heparin, warfarin
• Supplement considerations
• 500 mg of dried ginger powder every 2-4 hours
Homeopathy
• Arsenicum – vomiting, diarrhea, anxiety
• Carbo vegetalis – severely depleted states, nausea,
vomiting
• Ipecac – nausea and vomiting with increased
salivation
• Nux vomica – nausea, dry retching, constipation
with urge
Acupuncture
• Acupuncture has a potential role in managing the
following cancer symptoms: pain, nausea and
vomiting, xerostomia, hot flushes, fatigue, anxiety,
depression, and insomnia.
•
Pan et al. Complementary and Alternative Medicine in the Management of Pain,
Dyspnea, and Nausea and Vomiting Near the End of Life: A Systematic Review. 2000.
Naturopathic Approaches
to Pain Management
Diana Quinn, ND
Hygeia Center for Healing Arts
Beaumont Hospital Integrative Medicine