Overmedication: Problems and Solutions
(Director’s Testimony to Senate Committee on Veterans’ Affairs, 4/30/14)
Witness Before the Senate Committee on Veterans’ Affairs
Josephine P. Briggs, M.D.
Director, National Center for Complementary and Alternative Medicine
National Institutes of Health
April 30, 2014
Chairman Sanders, Ranking Member Burr, and members of the Committee, thank you for inviting me to be here today to discuss the need to improve pain management strategies to reduce overmedication and opioid dependency. My name is Josephine Briggs, M.D., and I am the Director of the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH), the Federal Government’s lead agency for supporting scientific research on complementary practices and integrative health interventions. Our mission at NCCAM is to define the usefulness and safety of complementary and integrative health practices and their role in improving health through rigorous scientific investigation. Our research priorities are driven by scientific promise and public health need. We support the study of complementary interventions, approaches, and disciplines across the continuum of basic, translational, efficacy, and effectiveness research.
Complementary, alternative, and integrative health practices are defined as having origins outside of mainstream conventional medicine. They include both self-care practices like meditation, yoga, and dietary supplements, and health care provider administered care such as acupuncture, and chiropractic, osteopathic, and naturopathic medicine. As these modalities are increasingly integrated into mainstream health care, NCCAM is committed to developing the evidence needed by the public, health care professionals, and policymakers to make informed decisions about their use and integration into medical practice. In addition to supporting the research, we disseminate the latest evidence-based information on these approaches to scientists, health care providers, and the general public through an information-rich website (www.nccam.nih.gov) and other media.
According to the Centers for Disease Control and Prevention, approximately 30 percent to 40 percent of Americans use complementary and integrative health practices, spending some $34 billion in 2007.1 This represents 1.5 percent of total health expenditures and 11 percent of out-of-pocket costs. These practices are increasingly being offered in hospitals and hospice settings. The most common reason cited for use of complementary and integrative health practices is for the alleviation of pain.
Pain is a public health problem of substantial impact. It affects more than 100 million Americans each year—more than the total affected by heart disease, cancer, and diabetes combined—and is estimated to cost the Nation $560-$635 billion each year in medical costs and lost productivity.2 While an important part of pain management, pharmaceutical approaches may provide incomplete relief and can carry serious side effects, including overmedication and opioid dependency and, in some cases, addiction. Commonly prescribed opioid pain relievers can be dangerous as even a single large dose can cause severe respiratory depression and death. Deaths from opioid pain relievers exceed those attributed to cocaine and heroin combined. Finding alternatives for pain management is needed.3
In 2011, after examining pain as a national public health problem, the Institute of Medicine (IOM) released a Consensus Report in 2011, entitled “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” The IOM report encourages Federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments, and to take steps to develop integrative pain management strategies. The report notes that ideally, most patients with severe persistent pain would obtain care from an interdisciplinary team using an integrated approach that would target multiple dimensions of chronic pain—including disease management, reduction in pain severity, improved functioning, and emotional well-being and health-related quality of life.
In addition, the Federal Government created an Interagency Pain Research Coordinating Committee (IPRCC) to enhance pain research efforts and promote collaboration across the government, to advance our fundamental understanding of pain, and to improve pain-related treatment strategies. Members include representatives of the Departments of Health and Human Services, Veterans Affairs (VA), and Defense (DOD), the scientific and medical communities, the public, and stakeholder groups. I serve as one of the NIH representatives. The IPRCC is developing a comprehensive population health level strategy for pain prevention, treatment, management, and research. One of the first efforts of the IPRCC was a thorough analysis of pain research across Federal agencies, resulting in the recently released “2011 IPRCC Federal Pain Research Portfolio Analysis Report”4 which revealed many areas of shared research interests between and across Federal entities, but no notable redundancies.
NCCAM participates in the NIH Pain Consortium to enhance and increase the coordination of pain research across NIH. The Consortium’s efforts include targeted initiatives such as the development of the first clinically-based data registry to help identify pain management interventions that are most effective for specific patient-types with chronic pain, led by the National Institute on Drug Abuse (NIDA), and the creation of standard research measures to assess chronic low back pain, which was spearheaded by NCCAM.
To improve pain education in health professional schools, the Pain Consortium established 12 Centers of Excellence in Pain Education to advance teaching and provide comprehensive curricula about the pathophysiology of pain, its assessment, diagnosis, management, and treatment. The curricula include the latest research results in complementary and integrative pain management, factors that contribute to both under- and over-prescribing of pain medications, and how pain manifests itself differently by gender, by age, and in diverse populations. In addition, NIDA, Medscape Education, and the White House Office of National Drug Control Policy developed two continuing medical education courses on practical guidance for physicians and other clinicians in screening pain patients for substance use disorder risk factors before prescribing, and in identifying when patients are abusing their medications. The courses use videos that model effective communication about sensitive issues, without losing sight of addressing the pain. To date, more than 80,000 health care professionals have completed these courses.
At NCCAM, an increasing proportion of our research budget is dedicated to studies examining promising non-pharmacological approaches for pain management, including mindfulness meditation, spinal manipulation, massage, acupuncture, and exercise forms, such as yoga and Tai chi. Some of these approaches are already being recommended by the American College of Physicians and the American Pain Society in their guidelines for the diagnosis and treatment of low back pain. NCCAM is interested in better understanding how these interventions work, for what type of pain conditions, and the optimal methods of practice and delivery. We also support Centers of Excellence for Research on Complementary and Alternative Medicine that bring a multifaceted interdisciplinary approach to research on pain. In addition, NCCAM recently established a new intramural research program that focuses entirely on pain using state-of-the-art neuroimaging and other advanced technologies to study the mechanisms of pain including the role of emotions and attention on the modulation of pain.
Last year, NCCAM joined NIDA, the National Institute on Alcohol Abuse and Alcoholism, and DOD in a joint initiative to conduct research on prevention and health promotion interventions to prevent alcohol and other drug abuse and associated physical and psychological health problems in Veterans and military personnel. NCCAM also issued a solicitation, along with NIDA and the VA, specifically focused on complementary and integrative approaches to managing pain and other symptoms such as posttraumatic stress, traumatic brain injury, substance use disorders, anxiety, and sleep disturbances often experienced by Veterans and military personnel. The initiative requested research approaches to study (a) mind-body interventions such as mindfulness- or meditation-based stress reduction approaches, (b) yoga, (c) acupuncture, (d) art therapy, (e) massage, and (f) cognitive-behavioral interventions. Grant applications are currently under review, and we look forward to funding multiple studies later this year. Research findings from these initiatives are expected to lead to enhanced patient care and improved pain and symptom management through better integration of evidence-based complementary approaches.
At my direction, a special Working Group of the National Advisory Council on Complementary and Alternative Medicine was recently formed to explore ways to foster rigorous research that will inform the use and incorporation of complementary approaches in military and veteran populations and promote collaboration among the VA, DOD, and NCCAM. The Working Group, chaired by Lloyd Michener, M.D., of Duke University, includes current and former VA and DOD officials. The group is charged with defining a research agenda for mind/body interventions for pain and symptom management, including identifying the most promising therapies and the next steps for development of large clinical trials. Experts will present perspectives of patients, Veterans, military personnel, and clinicians to help shape the Working Group’s recommendations.
In summary, NIH and NCCAM are committed to improving understanding and treatment of pain and related conditions for all Americans including military personnel and Veterans. We expect research results to provide information to the public and health care providers and policymakers. I appreciate the opportunity to appear before this Committee, and I look forward to answering any questions. Thank you.
Josephine P. Briggs, M.D.
Director, National Center for Complementary and Alternative Medicine
Josephine P. Briggs, M.D., an accomplished researcher and physician, is Director of the National Center for Complementary and Alternative Medicine. Dr. Briggs brings a focus on translational research to the study of complementary and integrative health practices to help build a fuller understanding of the usefulness and safety of these approaches.
In addition to her position at NCCAM, Dr. Briggs has served on several key trans-NIH committees, including the NIH Steering Committee; the Clinical Center Governing Board; the Advisory Board for Clinical Research; the Executive Committee of the NIH Pain Consortium; and as co-chair of the Executive Committee of the NIH Common Fund’s Health Care Systems Research Collaboratory.
Dr. Briggs received her A.B. cum laude in biology from Harvard-Radcliffe College and her M.D. from Harvard Medical School. She completed her residency training in internal medicine and nephrology at the Mount Sinai School of Medicine, New York, where she was also chief resident in the Department of Internal Medicine and a fellow in clinical nephrology. She then held a research fellowship in physiology at Yale School of Medicine, New Haven, CT. Dr. Briggs was a research scientist for 7 years at the Physiology Institute at the University of Munich, Germany.
In 1985, Dr. Briggs moved to the University of Michigan, Ann Arbor, MI, where she held several academic positions, including associate chair for research in the Department of Internal Medicine and professorships in the Division of Nephrology, Department of Internal Medicine and the Department of Physiology. Dr. Briggs joined NIH in 1997 as director of the Division of Kidney, Urologic, and Hematologic Diseases at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) where she oversaw extramural research activities. While at NIDDK, she co-chaired an NIH Roadmap Committee on Translational Core Resources. In 2006, she accepted a position as senior scientific officer at the Howard Hughes Medical Institute. In 2008, she became NCCAM’s second director.
Dr. Briggs’ research interests include the renin-angiotensin system, diabetic nephropathy, circadian regulation of blood pressure, and the effect of antioxidants in kidney disease. She has published more than 175 research articles, book chapters, and scholarly publications. Dr. Briggs also has served on the editorial boards of several journals (including the Journal of Laboratory and Clinical Medicine, Seminars in Nephrology, and Hypertension) and was deputy editor for the Journal of Clinical Investigation. She is an elected member of the American Association of Physicians and the American Society of Clinical Investigation and a fellow of the American Association for the Advancement of Science. She is a recipient of many awards and prizes, including the Volhard Prize of the German Nephrological Society, the Alexander von Humboldt Scientific Exchange Award, and NIH Director’s Awards for her role in the development of the Trans-NIH Type I Diabetes Strategic Plan and her leadership of the Trans-NIH Zebrafish committee.
1. Nahin RL, Barnes PM, Stussman BA, et al. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. CDC National Health Statistics Report #18. 2009.
2. IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.
3. Drug Facts: Prescription and Over-the-Counter Medications, National Institute on Drug Abuse, National Institutes of Health, May 2013. www.drugabuse.gov/publications/drugfacts/prescription-over-counter-medications, accessed April 28, 2014.
4. National Institutes of Health, National Institute of Neurological Disorders and Stroke, Office of Pain Policy. 2011 IPRCC Federal Pain Research Portfolio. Analysis Report. Available at iprcc.nih.gov/news/IPRCC_Pain_Portfolio_Analysis_Report.pdf (955KB PDF). Accessed April 28, 2014.