Hi guys! There are tons of doctors and researchers out there dedicated to improving the way that people with chronic pain are treated. Doctor Helene Langevin is one of those people. As the director of the National Center for Complementary and Integrative Health at the National Institutes of Health, Dr. Langevin oversees research on the fundamental sciences and usefulness of complementary and integrative health approaches. She has done research on the role of connective tissue in chronic musculoskeletal pain, the mechanisms of acupuncture, and movement based therapies.

Can you tell me how you became interested in the field of pain medicine?

Well, I was practicing medicine quite a long time ago in internal medicine and endocrinology. I realized that no matter what kind of doctor you are, or any kind of healthcare provider, chronic pain is something that you have to deal with. Many patients, regardless of their specific medical problem, have pain. Oftentimes, pain is the main reason people go to the doctor or hospital. So I was seeing a lot of people with chronic pain and I felt like I didn’t have enough to offer.  I’ve experienced chronic pain myself. It’s pretty rare for a person to not deal with it at some point in their lives. 

I completely agree. You really see it within every specialty of medicine. When you were working in endocrinology, were you seeing specific types of chronic pain or a variety of chronic pain conditions?

I saw a variety, but I also saw a lot of diabetic neuropathy. That can be very serious. This is a kind of burning pain that people can have and it can be quite troublesome. I was also working as a general internist so I was every variety of chronic pain.

And then eventually you ended up becoming the director of the National Center for Complementary and Integrative Health. How did you end up in that position?

I started doing research over 25 years ago on the mechanism of acupuncture as well as manual and movement based therapies. I became interested in connective tissue as a substrate for a part of the body that we don’t know a lot about. We think it’s very important for musculoskeletal function and pain. 

I did a lot of research back at the University of Vermont for a long time and then transitioned over to the OSHA Center for Integrative Medicine at Harvard Medical School. Brigham and Women’s Hospital was where I really started getting interested in integrative health as a whole.

Then I transitioned over to the NCCIH as the director. The NCCIH is the lead agency for research on complementary therapies. A big portion of what the NCCIH funds is related to pain research.

When we’re talking about treatments that are considered complementary or integrative, what exactly do those words mean? How is this different from what we normally do within the healthcare system?

We used to refer to complementary therapies as alternative therapies. That was a long time ago because they were seen as alternatives to medical practices. We don’t think about it that way anymore. We now believe that complementary therapies should be used together with conventional therapies. They should also be integrated, meaning that you should not have two different sources of healthcare. For example, seeing your regular doctor and an acupuncturist separately. We really feel that the care should be integrated and that your healthcare providers should be working together to offer the best coordinated care.

There are now several models of integrated pain care that combine conventional practices like medications with other treatments such as physical therapy and cognitive behavioral therapy. They may also use some complementary therapies like acupuncture, massage, spinal manipulation, and those kinds of things. We try to do whatever is best for the patient at the time, but in a way that’s coordinated.

I see the logic in that. I did the best when I started working with a pain psychologist but I had also been working with a physical therapist for some time. Working with different modalities gave me a better chance of being able to treat my pain.

We know that chronic pain is complex. As you mentioned, the biopsychosocial approach makes a lot of sense. There are some aspects of pain that are more body based. For example, myofascial pain can involve some problems that are going on in the actual tissues, muscles, and fascia.

There can be a psychological component to this because once people start having pain, it’s going to change how you move, how you go about your day, and your sleep. There are a lot of things that need to be addressed from the psychological side as well as the body.

When someone is struggling with chronic pain and they’re looking for treatments like what you have been describing, how can they access these types of treatments?

Looking for an integrative pain program is a good place to start. Unfortunately, they’re not always available where people live. Or they can see their primary care provider and ask where to find an integrative program. Sometimes doctors know about these types of programs and other times they don’t. Asking is always a good place to start.

The challenge is finding a program that is reimbursed by insurance. That’s very difficult. It’s not always available. We’re working really hard to generate the research that is needed in order for more of these comprehensive pain programs to be covered by insurance. It’s starting to happen. There are more and more of these comprehensive pain programs that are reimbursed and covered by some health plans. We just need a lot more progress in this area.

Yeah, I’ve noticed that more insurances are starting to cover acupuncture. That’s a small amount of progress.

You also mentioned that you have done research on acupuncture in the past. When I have asked people about their experiences with acupuncture, some people say it was very effective for decreasing their pain and other people say that it didn’t do anything for their pain. What exactly is the research telling you about the effectiveness of acupuncture?

Acupuncture can be considered to be what we call an analgesic. If someone has acute pain, acupuncture can be very effective, especially when you stimulate the needles with electrical acupuncture. That can be a very effective way to temporarily reduce pain. It’s a little bit like an analgesic. It’s like taking ibuprofen.

Acupuncture increases the pain threshold so that the sensation of pain becomes less strong. It’s often temporary. It works by causing the release of endogenous opiates. This involves the brain and higher centers within the brain. It is well documented. The thing is that it doesn’t last. The effect wears off just like an analgesic. This can be disappointing for a lot of people because they think that it didn’t help them in the long term.

Now there’s another aspect of acupuncture which is what we call health restoration. This is more long term. Treating a symptom is often temporary. Truly restoring health or resolving the pain is a very different thing. It has to do with slowly working through all the different layers of pain. For example, this may involve addressing inflammation within the tissues, a person’s movement patterns, teaching relaxation strategies, and even looking at their sleep. It’s more of a learning process and acupuncture can be useful for that. It can help with learning and long term recovery.

There was a study where people with back pain received acupuncture for three months. A year later, these people still had significant pain reduction even though they were no longer receiving acupuncture. This is a case where there was long term resolution or a restoration of health. Not everyone experiences that, but it has certainly been documented.

Do we understand why acupuncture works for some people and not for others?

That’s a really good question. There are no two people who are alike. There are genetic differences and some people are more sensitive to pain. There are genes that control how our dopamine circuits work and how a person engages in both the pain experience and the resolution of pain. There could be other elements, but they have not been fully elucidated yet. There are also differences in how people approach non-pharmacological therapies.

A lot of people are more interested in symptomatic treatment like a pill. And sometimes that’s what works. Not everyone wants to engage in therapies. It depends on what people are interested in and what their expectation is. It’s definitely not for everyone. I think there is both  genetic and behavioral differences between people that may make them more or less likely to benefit from a treatment. It’s highly individual.

I’ve also heard that there are different types of acupuncture, one of which is electroacupuncture. Is this more effective than the usual type of acupuncture that is offered?

For temporary pain relief, yes. Electroacupuncture is really good at lowering down the pain amplification. When you have pain for a while, it often gets worse and worse. Electroacupuncture can be good at lowering this type of pain and intensity. There’s not really any evidence that electroacupuncture is any better at resolving pain in the long run. It’s more for short term pain relief.

You’ve also mentioned that you have done some research on the role of connective tissue in musculoskeletal pain, which is not something I hear about too often. Can you tell me a little about that as well?

You have probably heard the word myofascial pain. Myofascial pain is based on the idea that muscles and connective tissue go hand in hand. You can’t really separate them. There’s connective tissue around the muscle, but also inside of the muscle. A lot of times, when people have pain in their shoulder, back, neck, and wherever else, you can feel knots in those areas. Sometimes pushing and massaging the area can help. We don’t understand very well yet what it is in the muscles or the connective tissue that causes these painful knots. As long as we don’t know what’s causing it, we don’t know how to develop treatments for it.

The NIH has a program called HEAL which stands for Help End Addiction Long term. It funds research to help resolve the opioid crisis. We have funded some awards and now I think there 13 awards aimed at developing markers of tissues in myofascial tissues that will be able to guide the development of effective treatments for myofascial pain. If you can’t measure something objective in the tissues, it’s hard to test the effect of the treatment. The hope is that with these new technologies to look at connective tissue and muscles in myofascial pain, we will be better at measuring the effects of treatments.

Can myofascial pain and knots be effectively treated with massage therapy?

Massage can help reduce pain. What we don’t know is if massage can reduce what’s going on in the tissues because we don’t have a way to measure the effectiveness.

When I had researched fibromyalgia, there was research on the use of myofascial tissue massage to decrease pain. 

Fibromyalgia is a very interesting condition. The problem seems to be in overall pain intensity throughout the whole body. We test their pain sensitivity in their arms, legs, and all over. They often have problems with sleep and some people with fibromyalgia also have depression and irritable bowel syndrome. It has a lot of different things associated with it. People with fibromyalgia can also have myofascial pain.

With all your years working in pain medicine, what are some changes you would like to see within the healthcare system for how chronic pain is treated?

First and foremost, there are many clinical guidelines. For example, for chronic pain the first line of therapy should be non-pharmacological things like exercise, massage, and acupuncture. Not drugs and especially not opiates. Unfortunately, these clinical guidelines are often not adhered to. So the first important thing is to make sure that we maximize the implementation of therapies that we know work.

One of the things we do at the NCH and NIH is to try and understand what barriers prevent these therapies from being used. Why is it that healthcare providers are not using these therapies like they should? Part of the barrier is insurance reimbursement.

It’s a bit of a chicken and egg problem. If these things are not reimbursed, then they’re not going to be prescribed. It perpetuates the problem. We are working with the Center for Medicare Services to try and develop the kind of evidence that they need in order to reimburse acupuncture, for example.  A lot of Medicare recipients are over 65 so we need data on that age population to see whether acupuncture is effective.

How do you get insurance companies to change what they’re willing to pay for? Is it research dependent?

I can’t speak to how insurance companies make their decisions. What we can try to do is provide the best evidence possible so that insurance companies are able to use that evidence to decide whether or not they’re going to cover something. It’s helpful if we can show a specific treatment being used in the healthcare system. 

We can also compare the effectiveness of integrative programs with non integrative programs. We can demonstrate which patients have less pain in the long run and what is more cost effective. We can look at which patients no longer needed to go to the ER. An emergency room visit can cost thousands of dollars. Taking care of people so that they don’t have to go to the ER will save a lot of money.

At the University of Vermont, there is a comprehensive pain program. They were able to show that when the hospital offered a bundle payment where the whole entire pain program was paid for, people had a significant reduction in visits to the ER. It’s a win-win for everyone, including the hospital. Once we can demonstrate that these types of programs work, more hospitals will adopt them.

We get a lot of chronic pain patients in the ER. I think they just don’t know any better. Our healthcare system does not do a good job of pointing people in the right direction.

People usually don’t know what to do. They can’t cope. These comprehensive pain programs give people tools to handle not just the pain, but also the stress that comes with the pain.

We have this system called the autonomic nervous system. It has the sympathetic nervous system which is an alarm that gets activated when people are under stress. Pain is a huge stressor. When people are in pain, their sympathetic nervous system kicks in and they become even more stressed. Then it affects their sleep which makes everything worse. The pain gets worse when you can’t sleep. 

So we give people tools to be able to reset the button on stress and calm down the sympathetic nervous system. When they can rest, they can relax, and the pain is no longer all consuming. They can finally sleep and they have more energy the next day. Maybe they can go for a walk.

Sometimes we think of pain as a vicious cycle. The more pain you have today, the more pain you’ll have the next day. But it can go in the other direction. If you can reduce the pain a little bit, get more sleep, and the next day will be better. This cycle can be reversed and that’s how pain can resolve.

Huge thank you to Doctor Helene Langevin for taking the time to do this interview. She is doing amazon things for the chronic pain community. I look forward to keeping up with her work.