CME: Alternative Therapy for Chronic Pain

CME: Alternative Therapy for Chronic Pain
Author Information (click to view)

Charles R. Elder, MD, MPH

Physician Lead, Integrative Medicine
Kaiser Permanente Northwest
Affiliate Investigator
Kaiser Permanente Center for Health Research

Charles R. Elder, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:


  • Discuss the findings of a survey of chronic musculoskeletal pain patients in a large health maintenance organization with the goal of determining how many use chiropractic care and acupuncture and the extent to which the electronic medical record captured the use of this care.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)


Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Charles R. Elder, MD, MPH, FACP
Discloses the following financial relationship with pharmaceutical or medical product manufacturers:
Site Principal Investigator: Sanofi Pharmaceutical Co.

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


Charles R. Elder, MD, MPH (click to view)

Charles R. Elder, MD, MPH

Physician Lead, Integrative Medicine
Kaiser Permanente Northwest
Affiliate Investigator
Kaiser Permanente Center for Health Research

Charles R. Elder, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

New research shows that patients with chronic musculoskeletal pain commonly seek acupuncture and chiropractic care for relief, but many do not tell their physicians about it. Efforts are needed to better communicate the treatments being used by patients to manage this pain.

The Institute of Medicine estimates that chronic musculoskeletal pain affects about 100 million Americans and costs the country nearly $600 billion each year. Caring for these patients is complex and multiple treatments are commonly used. Pharmaceutic therapies are frequently administered to manage pain, but the efficacy of using these agents for chronic conditions has been questioned in clinical research. Furthermore, both prescription medications and over-the-counter drugs for pain can be costly and may lead to significant adverse effects. In addition to drug-related side effects, other more serious issues like addiction, abuse, and diversion of medications can make caring for these patients even more challenging.

Studies show that acupuncture and chiropractic care are popular alternative treatments used by patients with chronic musculoskeletal pain. Many health insurers cover these options for pain management, but this coverage is often limited. Some insurers allow patients to refer themselves for acupuncture and chiropractic care while others require primary care physicians to give a referral. Despite this knowledge, little is known about how often these alternative therapies are used and whether patients use health plan resources to access these services.  Also, few studies have explored clinician communication regarding these treatments.


A New Data Analysis

In a study published in the American Journal of Managed Care, Charles R. Elder, MD, MPH, and colleagues surveyed chronic musculoskeletal pain patients in a large health maintenance organization (HMO) to find out how many of them use chiropractic care and acupuncture and the extent to which the electronic medical record (EMR) captured the use of this care. “Until now, we haven’t had a good grasp on how often this care is used by patients,” says Dr. Elder. “We also didn’t know how often clinicians were talking to their patients about this care or how often it was being captured in the EMR.”

Dr. Elder and colleagues received survey responses from more than 6,000 Kaiser Permanente Northwest members who met EMR diagnostic criteria for chronic musculoskeletal pain. Results showed that many HMO participants had used acupuncture, chiropractic care, or both. Among the findings:

  • 32% reported acupuncture use.
  • 47% reported chiropractic care use.
  • 21% used both acupuncture and chiropractic care.
  • 42% used neither acupuncture nor chiropractic care.

Importantly, 25% of acupuncture use and 43% of chiropractic care use was undetected by the EMR.


More Communication Needed

Researchers also found that 35% of patients who used only acupuncture and 42% of patients who used only chiropractic care did not discuss this care with their HMO providers (Table). “Despite the fact that patients are using acupuncture and chiropractic care, many don’t discuss it with their healthcare providers,” says Dr. Elder. “Too often, doctors aren’t asking about these alternative treatments, and patients aren’t volunteering the information. Clinicians should make an effort to ask if alternative pain therapies are being used during patient encounters.”

The study also found that chiropractic users who accessed care out of their HMO plan tended to be older, were more likely to use long-term opioids, and had more pain diagnoses than those who accessed care by way of clinician referrals or self-referrals. Similar findings were observed among patients who used acupuncture through a clinician referral.


Considering the Implications

Results of the analysis suggest that patients often access acupuncture and chiropractic care, but much of this use occurs outside of the integrated healthcare system, and thus goes undetected by the EMR. It is likely that this situation is occurring throughout healthcare systems in other parts of the United States.

Alternative treatments can be effective, but it is important to have open communication between doctors and patients. “We can do a better job advising our patients and recommending treatments if we know what they’ve already tried and what has worked in the past,” Dr. Elder says.


Striving for Better Care

The study notes that improving the integration of acupuncture and chiropractic care offers opportunities to develop better pain management algorithms and to use available resources more efficiently. Clinicians should assume that many of their patients with chronic musculoskeletal pain are receiving acupuncture and chiropractic care.

“We also found that almost all patients who did not share information about acupuncture or chiropractic care use would tell their provider if they were asked about it,” Dr. Elder says. “This further emphasizes the importance of routinely raising questions about this topic during patient encounters. Engaging patients in the discussion about acupuncture and chiropractic use can provide information to optimize care. These discussions can also reinforce self-management efforts and may enhance the coordination of care to further improve outcomes.”


Charles R. Elder, MD, MPH, is the Physician Lead of Integrative Medicine at Kaiser Permanente Northwest, and an Affiliate Investigator at Kaiser Permanente Center for Health Research.

Charles R. Elder, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Readings & Resources (click to view)

Elder C, DeBar L, Ritenbaugh C, et al. Acupuncture and chiropractic care: utilization and electronic medical record capture. Am J Managed Care. 2015 Jul 20 [Epub ahead of print]. Available at:

For a link to a press release, video, and infographic on the article by Charles R. Elder, MD, MPH, and colleagues, go to

DeBar LL, Elder C, Ritenbaugh C, et al. Acupuncture and chiropractic care for chronic pain in an integrated health plan: a mixed methods study. BMC Complement Altern Med. 2011;11:118.

Elder C, Ritenbaugh C, Aickin M, et al. Reductions in pain medication use associated with traditional Chinese medicine for chronic pain. Perm J. 2012;16:18-23.

Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011;155:325-328.

1 Comment

  1. As a chiropractor that also does acupuncture, I’d like to add to your article that one reason, a major reason, that I don’t believe patients communicate their use of alternative medicines has to do with the medical community’s reaction to such knowledge. I have had countless patients tell their medical doctor that they are using our services only to have that medical doctor belittle my profession as well as the patient for using my office, even attempting to dissuade the patient from seeing us. As a result, our patients have learned to keep all activities their medical doctor might not approve of to themselves. Additionally, we have been forced to keep our referrals to medical doctors anonymous. In the past when we referred to medical doctors the patient would regularly come back to tell us what all the medical doctor had to say about our profession and the patient for using us. Not wanting our office or the patient to go through that stress we now typically remain anonymous. If we all want better communication between health providers, and we do need that, then we need better acceptance from the medical profession. We encourage patients in our office tell us everything, and we never admonish them for anything they do- even home remedies that might sound silly to most health professionals. As a result, our patients have an open dialogue with us. If the rest of the medical profession wants to know when their patients are using alternative therapies, I believe the biggest factor would be their acceptance of such treatments and their acceptance of a patient’s right to choose such treatments. Until then I have no doubt that patients will opt to keep such activities to themselves.


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