Free Complementary And Alternative Medicine For Pain In Sickle Cell Disease Essay Sample
There is controversy regarding the use of complementary and alternative medicine (CAM) in the nursing profession despite its widespread use in the population. Thus, it is difficult to make clinical decisions as to employing CAM in the management of pain in sickle cell disease. Resolving the controversy requires an understanding of the history of CAM use in the United States and worldwide and in the nursing profession. It is also important to know how CAM is regulated. Further, the factors contributing to the controversy in nursing must be explored along with the evidence supporting CAM for pain relief. Actions must be taken to address the contributory factors and underscore the role of nurses in the effort. Based on the aforementioned information, recommendations are made in regard to CAM in sickle cell disease pain management. Areas requiring further research are identified.
Persistent pain is a common experience among sufferers of chronic illness such as sickle cell disease (SCD). Pain in this disorder arises from red blood cells clumping together and occluding blood vessels. While pharmacologic therapy is available and can be used among SCD patients, long-term use of analgesics has side effects that can compromise patient safety and health. Complementary and alternative medicine (CAM) is an alternative or adjunct treatment to pharmacological pain relief methods but is currently controversial. This paper explores the issue and its implication to nursing and presents recommendations and areas of future research.
History of CAM in the World and in the United States
In a 2002 survey, CAM utilization was noted to have risen to 62% in the U.S. from 42% representing a 20% increase and a substantial component of the health care system (Helms, 2006). The rise paralleled the similar increase in CAM use in Australia, Japan, and developed countries in Europe. The reason behind CAM utilization is its holistic nature as it was more compatible with the individual beliefs and values of patients regarding health and wellness (Helms, 2006). The use of CAM was also seen as overcoming the highly impersonal nature of the biomedical health model. Moreover, contributory factors to high CAM utilization were helplessness, distrust of the effectiveness of Western medicine, and chronic pain (Callahan, 2009).
Moreover, Clarke et al. (2015) and Black et al. (2015), in their studies of CAM utilization, revealed the most commonly used approaches in the American pediatric and adult population. Non-vitamin and non-mineral dietary supplements such as fish oil, ginseng, ginkgo biloba, sylimarin, garlic, cranberry, and probiotics were the most commonly used among both children and adults. In adults, deep breathing was second most common followed by yoga, qi gong, and tai chi. Chiropractic and osteopathic care were fourth most common followed by meditation. In children, chiropractic and osteopathic care were second most common followed by yoga, qi gong, and tai chi.
The widespread use of CAM in modern times in the U.S. prompted the National Institutes of Health to create the Office of Alternative Medicine in 1992 that became the present National Center for Complementary and Alternative Medicine (NCCAM) (Helms, 2006). The NCCAM conducts research on different modalities and provides information to the public. In 2000, the White House Commission on Complementary and Alternative Medicine was established with the task of formulating national policies on the healthy and safe use of CAM products and therapies (Helms, 2006).
History of CAM in the Nursing Profession
The acceptance of CAM in the nursing profession began with Florence Nightingale who recognized that nature can act to heal a patient as long as the nurse ensures the best conditions for this to occur (George, 2011). Madeleine Leininger’s theory of transcultural nursing also promoted the respect of patients’ culture-based CAM practices. Before the national initiatives on CAM, the American Holistic Nurses Association (AHNA) had already been established in 1981 for the purpose of integrating CAM in the traditional Western model of care (Helms, 2006). Jean Watson, in 1995, further added alternative medicine as an area where nurses could apply the theory of human caring. Journals were established as well to motivate research and dissemination in this area of nursing.
At the time that national policies were laid down pertaining to CAM in the early 21st century, the Association of American Medical Colleges promoted the integration of CAM courses in the medical curriculum (Helms, 2006). This event compounded with the expanding roles of nurses into nurse practitioners prompted a similar change in the nursing curriculum. Providing CAM interventions is congruent with holistic patient care that considers patient beliefs, values, and preferences and is recognized as a viable strategy in improving the quality of care. Pioneer schools of nursing such as the University of Minnesota and the Rush University College of Nursing adopted holistic nursing curricula with the integration of CAM in the program philosophy (Helms, 2006). Several NP programs also adopted CAM as one program in their curricula. However, the majority only included CAM as a topic in elective courses.
Laws Regarding the Use of CAM in United States
The US Food and Drug Administration is the agency that regulates CAM production and use. Products and therapies are regulated based on their classification under the Federal Food, Drug, and Cosmetic Act and the Public Health Service Act. The classifications are biological product, drug, cosmetic, device, dietary supplement, food, and food additive (US FDA, 2006). For instance, if a CAM modality involves juice therapy, then it is considered food and must fulfill the requirements of the hazard analysis and critical control point system. Acupuncture and biofield therapy are considered medical devices as the former employs needles and the latter uses energy fields (US FDA, 2006). As such, both are subject to regulations pertaining to medical devices. In addition, some CAM modalities are subject to professional regulation through certification and licensure by such bodies as the Board of Chiropractic Examiners and the Board of Osteopathic Medicine.
Nurses’ awareness and knowledge of CAM promotes its optimization in the management of pain and other symptoms. In a survey of 132 Pakistani registered nurses in 8 inpatient oncology units in tertiary hospitals, more than 80% of the participants reported not having heard of moxibustion and cupping, and more than 50% were not aware of aroma therapy, tai chi, magnetic field therapy, biofeedback, chiropractic interventions, reflexology, and rolfing (Somani et al., 2014). The CAM therapies known by more than 80% of the nurses were herbal medicine, prayer, spiritual healing, massage, homeopathy, and yoga. While 71% of the participants believed that CAM can enhance the patient’s health status, 65% have witnessed patients employing such therapies, and 55% have used CAM for their family members, CAM education and certification was low at 25% and 4%, respectively (Somani et al., 2014).
The findings of Somani et al. (2014) are validated by the qualitative study conducted by Smith & Wu (2012) among Taiwanese nurses. One of the themes that emerged from the interviews was the lack of a clear definition which suggested inadequate knowledge about the therapy. Their reports of limited experience underscore the lack of education and training as well, a gap that is not being addressed in their respective organizations. A third theme is high interest in CAM. Similar to the Pakistani nurses in the study by Somani et al. (2014), the Taiwanese nurses had a very positive attitude towards CAM. They reported the desire to participate in CAM continuing education activities.
In contrast, Buchan et al. (2012) documented that 80% of the nurses in their survey were themselves using CAM. The most common therapy used was massage, cranberry juice, and cod liver oil. In addition, a greater number of the participants at 95% also had positive attitudes towards CAM believing that it was effective. Similarly, the nurses had no CAM-related formal education and were also interested in attending such activities because patients often asked for advice about CAM. Improving knowledge on CAM was perceived as helping them gain confidence in educating patients.
Anderson and Taylor (2011) discussed the evidence pertaining to biofield therapy in the management of cancer pain. The range of therapies under this modality includes healing touch, polarity therapy, reiki, johrei, and therapeutic touch. These therapies induce relaxation and reduce stress that supports the body’s natural physiological responses towards healing. The authors cited randomized controlled trials and quasi-experimental studies demonstrating the effectiveness of biofield these therapies in minimizing pain and discomfort related to the disease process.
The studies showed reduced pain with the use of healing touch in patients with leukemia and non-hematologic cancers (Anderson & Taylor, 2011). Pain reduction was also noted in a sample of women with cancer who received therapeutic touch. Reikki compared with opioid therapy was also found to be more effective in reducing pain in a sample of patients with chronic pain. Despite the promising outcomes, the methodologies employed, i.e. small sample sizes and non-use of comparison groups, require further studies with higher quality research methods to generate support of biofield therapy.
Meanwhile, Abou-Setta et al. (2011) conducted a systematic review on the effectiveness of different pain management interventions in the management of hip fracture pain. Nerve blockade, systemic analgesia, spinal anesthesia, traction, neurostimulation, multimodal pain management, rehabilitation, and CAM were the interventions compared. Only 2 studies were available for CAM compared to 32 studies on nerve blockade and 30 studies on spinal anesthesia. The CAM interventions were acupressure and relaxation therapy. The review showed inadequate evidence to make recommendations about CAM highlighting the need for more studies not only on the above modalities but other CAM therapies as well.
Specifically in sickle cell disease, Thompson and Addison (2013) noted that prior studies showed high CAM utilization among pediatric patients with this disorder. Specifically, Sibinga et al. (2006) revealed that 54% of a sample of children used spiritual and energy healing as well as prayer while 28% used exercise, relaxation, diet, and imagery. The participants and their families concurred that CAM was effective in pain reduction. In their survey of African American adults with the same illness, Thompson and Addison (2013) found that pain was prevalent in 65.1% of the respondents, and 90% had taken daily pain medications for the six months prior to the survey. Nearly 92% were also taking CAM for pain which is higher compared to pediatric patients. CAM practitioners were perceived by patients as more empowering and providing a personal touch in their treatments.
Options for Approaching the Dilemma
Clearly continuing professional education can help standardize clinical practice in relation to CAM especially in settings such as oncology where disease symptoms and medication side effects are a continuing health issue among patients. Developing an appropriate curriculum in the workplace would entail assessment of the nursing staff’s learning needs. Rojas-Cooley & Grant (2009) conducted a survey of cancer nurses using the Nurse Complementary and Alternative Medicine Knowledge and Attitude instrument with the addition of an open-ended question on the nurse’s individual comments. Data analysis showed that the average knowledge score of CAM was 70% with generally positive beliefs, roles, and, practices among participants. The assessment will guide the selection of topics for inclusion in an in-service educational activity.
However, the integration of CAM courses in undergraduate nursing can also alleviate the lack of knowledge. In a survey of Turkish nursing students, Yildirim et al. (2010) found that 57.8% had favorable attitudes about CAM as they thought related interventions were integral components of their future clinical practice. More than 61% thought CAM concepts and skills should be integrated in the BSN curriculum. The students were most familiar with imagery and massage interventions only. Helms (2006), in her article, reiterates the need to integrate CAM in the nursing curriculum given that a significant proportion of the public are already using a wide variety of CAM modalities and the utilization rate has been increasing.
Moore (2010) emphasizes that the integration of CAM in nursing education should go beyond just including it as one topic among many in elective subjects as has been the practice of the majority. CAM should be regarded as a safety issue and thus a priority given that patients do consume related products such as supplements and herbal medicine as well as engage in modalities such as acupuncture and reflexology. Like any treatment, nurses must be able to promote what is good for the patient and reduce harm.
For this reason, CAM should be a major and required area of study and not merely an add-on or an option. Moore (2010) further points out that the wealth of research on CAM justifies this approach to integration. Rather than skim over CAM knowledge, it is important for nursing programs to permit students to explore it in-depth to resolve issues in relation to evidence-based practice and culturally congruent care. For instance, patient assessment should elicit data on CAM use because it may not be readily disclosed by patients (Rojas-Cooley & Grant, 2009).
In relation to EBP, greater integration of CAM in NP programs also addresses the dilemma on the use of CAM. As advanced practice nurses with the capacity to provide primary care, NPs often encounter patients who have the financial resources to use CAM in addition to conventional care or patients who lack the resources for conventional care and therefore resort to CAM (Cattell, 1999). A study by Nahin et al. (2009), using CAM utilization data from the 2007 National Health Interview Survey, showed that for that year, the out-of-pocket costs of CAM amounted to $33.9 billion, about 67% of which were for products, materials, and classes. Approximately 44% of total costs were for non-vitamin and non-mineral supplements. More than 30% was spent on 354.2 million visits to CAM practitioners typically for body-based and manipulative treatments.
As such, CAM is now an established sector in the health care industry and cannot be ignored. However, the lack of standards on CAM as treatment and its exclusion from reimbursement implies that NPs cannot actively prescribe it even if there are clear benefits for the patient and the patient expresses his or her preference for such treatment. Therefore, NPs must take on a more active role in evaluating CAM modalities in terms of effectiveness, acceptability, and costs towards the creation of standards and advocate for its coverage (Cattell, 1999). These initiatives are consistent with ethical nursing practice.
Lakasing and Lawrence (2010) demonstrates the point made by Cattell (1999) on the need for NPs to take a more active role by emphasizing that NPs can deliver CAM therapies themselves. The authors describe reflexology as an alternative therapy wherein an increasing number of physicians and nurses have obtained training in. Lakasing and Lawrence (2010) described the history, mechanism of action, clinical indications, contraindications, and evidence base of this therapy. The authors also provided a description of the procedure. Thus, their article is a sample of a structured approach that nurses and NPs can adopt to aid their provision of patient education or bedside interventions.
Nursing Standards on CAM in Sickle Cell Disease
The general practice of CAM is guided by the standards of holistic nursing developed by AHNA (Mariano, 2012). The standards state that nurses must integrate CAM treatment to meet patients’ physical, psychological, and spiritual needs. This must be planned in collaboration with the patient and family. Counseling and information on CAM must be provided as well to assist in the patient and family’s decision making. Related treatments and interventions must be monitored and evaluated for effectiveness. The nurse practitioner must have sufficient knowledge of pharmacology, psychoneuroimmunology, the CAM modality, and underlying evidence when prescribing. However, there are no standards pertaining to CAM in sickle cell disease. In their guidelines for the management of acute pain in sickle cell disease, the King’s College Hospital Department of Hematology includes a section on CAM but only enumerates the possible modalities (Rees, 2003). The lack of standards or guidelines is due to inadequate research in this area of care, a fact that the NCCAM (2012) also acknowledges.
Implications for Nursing
Nurses in advanced practice must take part in CAM education and training programs and actively evaluate different CAM interventions for them to provide effective, holistic, and evidence-based treatment and education (Cattell, 1999). Nurse educators must ensure that undergraduate and post-graduate curricula incorporate the development of knowledge, skills, and attitudes on CAM in a manner wherein nurses can adequately meet the informational and holistic needs of patients through direct care and advocacy within the health care team (Moore, 2010). On the other hand, nursing administrators should initiate the development of policies and guidelines regarding CAM to ensure related standards are adhered to by the staff. Nurse administrators must also be at the forefront of quality improvement initiatives in relation to CAM. Nurse researchers play an equally important role in generating, synthesizing, and disseminating evidence on CAM practice and education.
In regards to using CAM in the management of sickle cell disease pain, the benefits are reduced pain and greater satisfaction of patients with care. However, there remains a lack of strong evidence supporting CAM therapies in pain reduction in this patient population. Thus, the nurse must ensure patient safety by ensuring the patient’s condition is an indication for a particular CAM treatment and it is not contraindicated. The nurse must integrate CAM in the plan of care with the patient involved in planning and decision making. Beforehand, information must be given on the level of evidence supporting the therapy, expectations on effectiveness based on the evidence, costs, possible benefits, and possible harms. Further, the nurse must evaluate and monitor for the effect of the CAM treatment.
Areas for Further Research
Given the paucity of research, there are many possible areas that must be targeted for future research. Potential research questions are as follows:
1. Are CAM treatments effective in reducing pain in pediatric patients with sickle cell disease compared with conventional treatments?
2. Are CAM treatments effective in reducing pain in adult patients with sickle cell disease compared with conventional treatments?
3. Which CAM treatment is the most effective in reducing pain in sickle cell disease?
4. What CAM interventions are adopted by nurses in managing patients’ pain in sickle cell disease?
5. Are CAM interventions more cost-effective in pain management in sickle cell disease compared with conventional treatments?
6. Which CAM intervention used in sickle cell disease pain management is the most cost-effective?
7. What are best practices in the delivery of CAM treatments for pain management?
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Anderson, J.G., & Taylor, A.G. (2011). Biofield therapies and cancer pain. Clinical Journal of Oncology Nursing, 16(1), 43-48. doi: 10.1188/12.CJON.43-48.
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Rees, D. (2003). Guidelines for the management of the acute painful crisis in sickle cell disease. British Journal of Haematology, 120, 744-752. Retrieved from http://www.bcshguidelines.com/documents/sicklecelldisease_bjh_2003.pdf
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