Integrative medicine in the elderly Focus on pain management

Integrative Medicine Clinical Centers Keys to Success: Innovative Programming, Education, and Collaboration

To present a broad overview of integrative medicine relevant to the field of pain management, summarize information for pain medicine practitioners, and highlight the possible role and incorporation of integrative medicine in daily practice. From 2002 to 2022, the percentage of American individuals using at least one of seven integrative medicine approaches has increased from 19.2 to 36.7%, including use for pain management. While literature has supported benefits in pain for some approaches, there is less robust evidence for other modalities. Higher risk modalities such as chiropractic manipulation, acupuncture, and supplement use remain controversial. A discussion of practical considerations and recommendations is provided for pain management providers who may encounter patients using integrative medicine or who may want to incorporate it into their practice. Integrative medicine encompasses a broad range of modalities, which have increased in use over the last two decades. Pain management providers should be educated about and consider including integrative medicine modalities into treatment plans. Risks and benefits of each modality must be considered and discussed with patients.

Setting a dutch integrative medicine research agenda: Results of a consensus-based strategy

Most people suffer pain at some stage of their lives. Therefore, pain is the most common reason to seeking therapeutic alternative or conventional medicine. Pain management particularly in chronic pain due to postoperative is systematically have been developed by various great recommendations that assist the health care practitioner and patient in making decisions about health care. In recent years, we have developed a better understanding of the pathomechanisms that link inflammation and peripheral sensitization about pain which can be overcome through an alternative treatment. This approach is known as complementary and alternative medicine (CAM). The development of the combined health approach has lately been known as Integrative Medicine, which seeks to restore and maintain health by understanding a series of patients’ unique circumstances and overcoming their various physical, psychological, environmental, and spiritual influences. Through “whole system” treatment will be to elaborate an integrated approach, by dhikr, hijamah, and herbal medicine for facilitating the transition from viewing “pain” only as a matter of specific bodily functions (specific) to a more holistic view at the systemic level through integrative medicine to health care with a broader holistic approach.

The future of integrative health and medicine in Saudi Arabia

A Clinical Hypnosis Handbook for Pain Management and Palliative Care

An important task facing hospitals is improving pain management without raising costs. Integrative medicine (IM), a promising nonpharmacologic pain management strategy, is yet to be examined for its cost implications in an inpatient setting. This institution has had an inpatient IM department for over a decade. The purpose was to examine the relationship between changes in patients' pain, as a result of receiving IM therapy, and total cost of care during an inpatient hospital admission. In this retrospective analysis, data from an EPIC-based electronic health record (EHR) patient demographics, length of stay (LOS), and All Patient Refined Diagnosis Related Groups (APR-DRG) severity of illness measures were utilized. IM practitioners collected and entered patient-reported pain scores into the EHR. The authors regressed the demographic, change in pain, LOS, and APR-DRG variables with changes in pain on total cost for the hospital admission. To estimate cost savings to the hospital, they computed the average reduction in cost associated with reduction in pain by multiplying the coefficient for change in pain by average total cost. A large, tertiary care hospital in Minneapolis, MN. Adult inpatient admissions, 2730, during the study period where patients received IM for pain and met eligibility criteria. IM services provided to inpatients. Change in pain on an 11-point numeric rating scale before and after initial IM sessions; total costs for hospital admissions. Both LOS and age were found to increase cost, as did being white, male, married, and having APR-DRG severity coded as extreme. For patients receiving IM therapies, pain was reduced by an average of 2.05 points and this pain reduction was associated with a cost savings of $898 per hospital admission. For patients receiving IM therapies, pain was significantly reduced and costs were lowered by about 4%.

Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine.

BackgroundA model for integrative medicine (IM) adapted to Swedish primary care was previously developed. The aim of this study was to explore the feasibility of a pragmatic randomised clinical trial to investigate the effectiveness of the IM model versus conventional primary care in the management of patients with non-specific back/neck pain. Specific objectives included the exploration of recruitment and retention rates, patient and care characteristics, clinical differences and effect sizes between groups, selected outcome measures and power calculations to inform the basis of a full-scale trial.MethodsEighty patients with back/neck pain of at least two weeks duration were randomised to the two types of care. Outcome measures were standardised health related quality of life (the eight domains of SF-36) complemented by a set of exploratory "IM tailored" outcomes targeting self-rated disability, stress and well-being (0-10 scales); days in pain (0-14); and the use of analgesics and health care over the last two weeks (yes/no). Data on clinical management were derived from medical records. Outcome changes from baseline to follow-up after 16 weeks were used to explore the differences between the groups.ResultsSeventy-five percent (80/107) of screened patients in general practice were eligible and feasible to enrol into the trial. Eighty-two percent (36/44) of the integrative and 75% (27/36) of the conventional care group completed follow-up after 16 weeks. Most patients had back/neck pain of at least three months duration. Conventional care typically comprised advice and prescription of analgesics, occasionally complemented with sick leave or a written referral to physiotherapy. IM care generally integrated seven treatment sessions from two different types of complementary therapies with conventional care over ten weeks. The study was underpowered to detect any statistically significant differences between the groups. One SF-36 domain showed a clinically relevant difference between groups that was also supported by a small distribution based effect size, i.e. vitality (-7.3 points, Cohen's d -0.34) which was in favour of IM. There was a clinical trend between groups showing that IM contributed to less use of prescription and non-prescription analgesics (-11.7 and - 9.7 percent units respectively) compared to conventional care. Exploring clinically relevant differences and the SF-36 as the basis for a main outcome measure showed that the sample sizes needed per arm to adequately power a full-scale trial depended on the target domain, i.e. ranging from 60 (vitality) to 339 (role emotion).ConclusionThis pilot study investigated the implementation of IM in the primary care management of non-specific back and neck pain. Recruiting patients and implementing IM in routine clinical practice was feasible. The results warrant further exploration into different perspectives and relevant combinations of outcome measures including the use of health resources, drugs and cost-effectiveness to help understand the relevance of IM in primary care. Future research should prioritise larger scale studies considering variability, pain duration and small to moderate treatment effects.Trial registrationClinical trials NCT00565942

Complementary medicine therapies are frequently used to treat pain conditions such as headaches and neck, back, and joint pain. Chronic pain, described as pain lasting longer than 3-6 months, can be a debilitating condition that has a significant socioeconomic impact. Pharmacologic approaches are often used for alleviating chronic pain, but recently there has been a reluctance to prescribe opioids for chronic noncancer pain because of concerns about tolerance, dependence, and addiction. As a result, there has been increased interest in integrative medicine strategies to help manage pain and to reduce reliance on prescription opioids to manage pain. This article offers a brief critical review of integrative medical therapies used to treat chronic pain, including nutritional supplements, yoga, relaxation, tai chi, massage, spinal manipulation, and acupuncture. The goal of this article is to identify those treatments that show evidence of efficacy and to identify gaps in the literature where additional studies and controlled trials are needed. An electronic search of the databases of PubMed, The Cochrane Library, EMBASE, PsycINFO, and Science Citation Index Expanded was conducted. Overall, weak positive evidence was found for yoga, relaxation, tai chi, massage, and manipulation. Strong evidence for acupuncture as a complementary treatment for chronic pain that has been shown to decrease the usage of opioids was found. Few studies were found in which integrative medicine approaches were used to address opioid misuse and abuse among chronic pain patients. Additional controlled trials to address the use of integrative medicine approaches in pain management are needed.

Battlefield Acupuncture

Complementary and Alternative Medicine (CAM) covers a heterogeneous spectrum of ancient to new-age approaches that purport to prevent or treat disease. By definition, CAM practices are not part of conventional western-style medicine because there is a perception of insufficient proof that they are safe and effective or because they are not taught in conventional medical and nursing schools. Complementary interventions are typically used together with conventional western-style treatments, whereas alternative interventions are used instead of conventional approaches. When combined with conventional practices they are often labeled Integrative Medicine (IM). Many people in the United States (US) use CAM and IM modalities1–7 and its use is increasing.2 In 1990, a national survey estimated that 33.8% of US adults used CAM modalities in the previous year,7 which increased to 42.1% in 19973 and 62% in the 2002 National Health Interview Survey (NHIS).1 These surveys included spiritual healing and "folk" medicine (remedies common, ethnically derived remedies used at home), in the CAM modality definition. Recently published results of the 2007 NHIS used a different CAM modality taxonomy and excluded these practices.2,8,9 When prayer specifically for health reasons was excluded, the 2002 and 2007 NHIS found 36% and 38.3%, respectively, of US adults reported using some form of CAM modality in the last 12 months.1,2 These national surveys only include civilian, noninstitutionalized individuals; they do not include our 1.8 million active duty military personnel and families. In the last 10 years, there has been an increase in interest and use of CAM modalities and IM in the military.9 This important segment of the US population receives health care from both military and civilian practitioners; and is subject to similar health risks as civilians plus additional physical, emotional, and cognitive stress of deployment with associated family separations for both the active duty member and families, and the consequences of combat.10,11 It would not be unexpected for military personnel to seek to improve their health through complementary practitioners, potentially at a greater extent due to health and performance expectations,10 and for the same reasons reported by civilians.1,2,11,12 This interest in CAM has been accelerated by the surge of chronic pain, chronic stress, and chronic symptoms associated with trauma and injuries from over a decade of wars in Iraq and Afghanistan.13 However, until recently there were little data to determine which CAM modalities are being used, how often, by whom, and for what purposes. Recently, these informational gaps are being filled in and the current picture is summarized below. USE OF CAM IN THE MILITARY The use of CAM in the military is higher than in the civilian population. Samueli Institute and Research Triangle International conducted the largest and most comprehensive survey of CAM use in over 16,000 active duty service members in all branches stationed both in the United States and overseas.14 Data were drawn from the 2005 Department of Defense (DoD) Survey of Health Related Behaviors among Active Duty Military Personnel, which draws on a worldwide, random sample of over 40,000 service members from all branches, sexes, races, and ranks.15 It asked about overall CAM use and 19 specific CAM therapies using a methodology that closely matched the NHIS used by the National Center for Complementary and Alternative Medicine.16 This military survey showed that approximately 45% of active duty military personnel reported using at least 1 CAM type in the previous 12 months. CAM use when not counting self-prayer was approximately 36%. The 8 most frequently reported CAM approaches included 4 mind body therapies (prayer for your own health: 24.4%; relaxation techniques: 10.8%; art/music therapy: 7.7%; exercise/movement therapy: 6.8%), 2 biologically based therapies (herbal medicine: 8.9%; high-dose megavitamins: 8.4%), and 2 manipulative and body-based methods (massage therapy: 14.1%; chiropractic: 5.2%). Eleven CAM types were used by <5.0% of respondents and 6 types were used by <1% of personnel. When both surveys were adjusted for the 2000 census bureau demographics, CAM use by military personnel was significantly higher than that of the general population (44.5% vs. 36.0% and 38.3% in the 2 NHIS surveys, respectively, P<0.001). Significantly more military personnel reported use of energy healing, guided imagery therapy, massage therapy, hypnosis, and relaxation techniques than civilians in both NHIS surveys (P<0.001) with more reported use of "folk" remedies, high-dose megavitamins, and spiritual healing by others than the 2002 NHIS survey (P<0.001) and more frequent use of biofeedback than the 2002 NHIS and 2007 NHIS surveys (P<0.001 and P<0.01, respectively). There were no statistical differences in reported use of acupuncture and homeopathy. Overall, the prevalence of CAM use in this study was consistent with smaller military surveys where 49.6% CAM use was reported by military veterans in the Southwestern United States,17 and with 37.2% use of 12 CAM modalities (excluding prayer) in US Navy and Marine Corps personnel.18 The vast majority of CAM health care occurs outside the military health system, some of it provided by TRICARE, the military's health insurance program. However, as in the civilian population, most CAM is paid for out of pocket by military personnel as TRICARE covers very few CAM modalities. Massage therapy, used by 14% or an estimated 137,000 personnel, is not a covered benefit, whereas biofeedback (for certain conditions) is covered. Chiropractic is the only CAM modality that is currently included in a systematic manner in the military health system; however, access to chiropractic practitioners is limited. In 2005, 54% of active duty personnel resided in areas served by chiropractic clinics, and the remaining 46% were not served by clinics because of living overseas (14%), in remote areas (5%), or in US installations without chiropractic clinics (28%).19 Herbal medicines and high-dose vitamins also are not covered by military health care. However, many military installations include a General Nutrition Center store on the premises where these products readily are available. Three CAM modalities (yoga, massage, and imagery), which are commonly used for stress management were used by military populations at an estimated 2.5–7 times the rate of civilians. The fact that military members and their families are seeking and personally paying for these therapies outside both direct military care system and the TRICARE System may reflect access problems in Military Treatment Facilities (MTF), a preference for CAM/IM over traditional modalities (ie, not turning away from traditional medicine but rather turning toward and preferring CAM/IM), growing concern about the results of traditional pharmacologically based treatments, and an increasing interest in and need for appropriate access to CAM modalities within the military health system to decrease symptoms and improve function for military members suffering from the "wounds of war." Unmonitored and uninformed use of CAM modalities in the military may have negative consequences on health and military performance. A number of large randomized, placebo controlled trials of herbal treatments20–22 and acupuncture7,23,24 have been negative, making the substitution of these CAM modalities for proven therapies risky. In addition, some CAM therapies, particularly herbal supplements, have been associated with potential harm through toxicity and herb/pharmaceutical interactions.25,26 Herbal medicines and nutrients in doses well above the Dietary Reference Intakes27 are 2 of the CAM modalities most commonly used by military personnel. With 45% of the over 1million active duty personnel reportedly using CAM modalities, and a steady increase globally, it is important to understand why military personnel are using CAM, the role these therapies should play in their health care, and for military health care providers to recognize, monitor, and integrate CAM modalities into their health care practices. OFFERINGS OF CAM IN MTF Two recent surveys have assessed the use of CAM across DoD medical facilities and evaluated their reported effects and attitudes by health care leaders in military MTFs. The first is in a report entitled "Integrative medicine in the military health system report to congress" by the DoD Undersecretary of Personnel and Readiness (P&R).28 In this survey, 29% (120) of 421 MTFs reported offering a total of 275 CAM programs including 213,515 CAM patient visits in calendar year 2012 for active duty members. The most visits were for chiropractic care (73%) and acupuncture therapy (11%). The report states that, of those doing evaluation of CAM they have found: (1) patients reporting a reduction in anxiety levels and improved sleep with meditation; (2) breath-based practices reportedly helped patients to remain sober and reduced overall stress levels; (3) patients using massage therapy noted 75% improvement of symptoms, including pain; and, (4) overall positive outcomes were reported by 50%–90% of patients using massage therapy. The Report also states that patients practicing yoga had declines in psychological symptoms and improvement in overall health. Over 30 research projects have been funded by DoD and have reported improvements in symptoms and sleep, reduction in anxiety and psychological symptoms across a number of CAM practices being used. The Report concluded that: "There is wide-spread use of CAM therapies across the [Military Health System] MHS. Providers and patients were interested in using CAM therapies even though many are not evidence-based. Some providers have added CAM therapies as an adjunct to conventional therapies for a holistic approach to patient management." The second survey, completed by Samueli Institute did a more in-depth survey of CAM availability across a more limited sample of both MTFs and morale, welfare, and recreation (MWRs) centers. The study examined the CAM services offered during the year 2013 in 47 DoD MTFs, and MWRs locations across all military service branches.29 Information was collected on the prevalence of CAM modalities provided; the attitudes and beliefs towards CAM among the leadership in the different facilities; the obstacles and barriers to access in military facilities; the funding sources for CAM offered at military facilities; and, whether CAM is part of the strategic plan for the future of health care delivery. In addition, information was collected on the provision of CAM treatments for highly prevalent conditions in military personnel (pain, combat-related stress, and rehabilitation), how beneficial medical leaders thought CAM was, and how practitioners were accredited to practice CAM modalities. The results of this survey showed that 30 (70%) of the 47 facilities surveyed provided some type of CAM service with most being provided for active duty service members (70%), followed by family members (43%) and retirees (36%). Less than 9% of the participants reported providing CAM services to federal employees, contractors, or members in the community. Overall, acupuncture and chiropractic were among the top 3 most prevalent practices followed by yoga and massage. For pain management the primary CAM modalities were acupuncture (36.2%), chiropractic or osteopathic medicine (27.7%), and breathing exercises (25.5%). For stress and stress-related conditions, the top modalities were acupuncture (25.5%), breathing exercises (21.3%), and biofeedback (17%). For wellness and fitness, offerings included weight management, diet-based therapies, and movement practices. In this Samueli Institute survey, 57% of medical leaders felt that CAM practices were either beneficial (40%) or highly beneficial (17%) with 40% being neutral on the benefit and 3.3% feeling CAM practices were not beneficial. Despite this generally favorable response, over 75% had no provision or guidelines for CAM use in their strategic plans. Still, 46% funded CAM services out of their general budget, with 12% receiving money from the Office of the Army Surgeon General, 8% receiving congressional money, and 4% private money for CAM. Only 10% reported any research or evaluation of CAM going on in their facility. This survey also examined the challenges to improving access to these practices. Although the majority of leadership responses (57%) rated CAM modalities as highly favorable or favorable, the identified obstacles and barriers for access to CAM in military facilities included (in order of frequency): (1) inadequate space to provide services; (2) patients do not know to ask for CAM; (3) CAM costs too much; (4) CAM is too time consuming; and (5) CAM does not contribute to workload coverage. The prevalence of CAM practices provided by MTFs and MWR across DoD shows 75% availability within MTFs, and 33% within MWR facilities and programs. There were no appreciable differences in availability of CAM across military branches. MINDING THE GAP: ALIGNING PATIENTS, PRACTICE, AND POLICY In the report to Congress by DoD P&R, it was recommended to evaluate CAM programs for safety and effectiveness, as well as cost-effectiveness and consider widespread implementation in the military health system if cost-effective. The criteria for how to do this are specified. Part 199 of Title 32, CFR, governs TRICARE benefits and restricts services to those medically necessary drugs, devices, treatments, or procedures for which safety and efficacy have been proven to be comparable or superior to established therapies. Established criteria state that unproven drugs, devices, treatments, or procedures may not be covered: (1) unless reliable evidence shows that any medical treatment or procedure has undergone well-controlled clinical studies that show maximum tolerated dose, toxicity, safety, or efficacy compared with standard treatment or diagnosis; (2) if the available reliable evidence is considered inadequate by experts who recommend further studies or clinical trials are needed. The criteria for making a determination of proven safe and effective to nationally accepted medical standards are evidence that comes from: (1) well-controlled studies of clinically meaningful endpoints published in referred medical literature; (2) published formal technology assessments; (3) published reports of national professional medical associations; and (4) published reports of national expert opinion organizations. However, these guidelines and criteria and not being applied appropriately to CAM modalities. Biofeedback is the only CAM practice currently covered under TRICARE guidelines, and TRICARE only covers biofeedback therapy for nerve injury, not stress management. The 2 most widely used CAM modalities (chiropractic and acupuncture) are excluded in Title 32 CFR section 199.4 (g) even though neither has been evaluated using TRICARE guidelines. In other words, none of the CAM modalities (with the possible exception of biofeedback) have been evaluated by the DoD or TRICARE using their own guidelines for determining which practices should be covered. Despite this, TRICARE declines to pay for acupuncture but will pay for biofeedback. Chiropractic (which also has not been evaluated by TRICARE guidelines) is provided to DoD beneficiates through MTFs but not through TRICARE. Chiropractic is currently being implemented across DoD even though research on the effectiveness of chiropractic in the DoD is only recently underway because of a Congressional mandate and special appropriation.30 Acupuncture is both widely accepted and used in the DoD and currently the Defense and Veteran's Pain Task Force is training medical practitioners in "Battlefield Acupuncture" (BA). BA is a specific auricular acupuncture protocol developed by Col (Ret) Richard Niemtzow, an Air Force physician, seeking to add a simple nonpharmacological pain management technique that could be used by a broad array of first responders and primary care providers to help reduce pain, reduce medication load, and improve function.31 Acupuncture has been shown to be superior to conventional therapy for several chronic conditions prevalent in the military, and has also been shown not to be due only to placebo effects.32 Samueli Institute has performed a comprehensive systematic review of acupuncture for the Trauma Spectrum Response, an important collection of comorbidities often experienced by service members after deployment.33 Recently, a comprehensive review of self-care CAM modalities for pain has been published in a special issue of Pain Medicine in which reasonable evidence for use of yoga, tai chi, and music were found for the treatment of pain.34 These areas are ripe for evaluation by the military and TRICARE Systems for possible inclusion into the array of services provided. CONCLUSIONS Over a decade of war has left hundreds of thousands of our service members and their families suffering from a range of psychological and physical injuries, many leading to or exacerbating chronic pain. They and their health care providers have surged ahead in seeking out drug-free and self-care healing practices to help them recover and return to wholeness in peacetime. The availability of efficacious CAM modalities adds needed access to a cadre of promising services and practices that promote healing and improved function with less medication and fewer unwanted side effects. However, DoD policy and priorities have not kept up with this surge, leaving the majority of active duty service members, veterans, and their families to fend for themselves, to pay for or go without the beneficial effects of CAM and IM practices. As stated in the DoD P&R report to Congress, "At this time, there are insufficient internal evaluations and reported results to determine whether the CAM programs being provided in the MTFs meet these [TRICARE] criteria." It is time for the DoD to step up their efforts to complete these evaluations and ensure that "sufficient evaluation" occurs in a more timely manner. Our long-suffering heroes deserve nothing less!

This manuscript reviews high-impact, peer-reviewed studies published from January 2014 to March 2016 that are relevant to pain management in primary care. Given the recent release of the US Centers for Disease Control and Prevention's "Guideline for Prescribing Opioids for Chronic Pain" emphasizing the primacy of nonopioid treatment, we focused our review on nonopioid pain management. Narrative review of peer-reviewed literature. We searched three article summary services and queried expert contacts for high-impact, English-language studies related to the management of pain in adults in primary care. All authors reviewed 142 study titles to arrive at group consensus on article content domains. Within article domains, individual authors selected studies approved by the larger group according to their impact on primary care clinical practice, policy, and research, as well as quality of the study methods. Through iterative discussion, 12 articles were selected for detailed review, discussion, and presentation in this narrative review. We present key articles addressing each of six domains of pain management: pharmacotherapy for acute pain; interventional treatments; medical cannabis; complementary and integrative medicine; care management in chronic pain; and prevention. Within each section, we conclude with implications for pain management in primary care. There is growing evidence for multiple nonopioid treatment modalities available to clinicians for the management of pain in primary care. The dissemination and implementation of these studies, including innovative care management interventions, warrant additional study and support from clinicians, educators, and policy-makers.

The blend of complementary alternative medicine (CAM) and traditional Western medicine is known as integrative medicine (IM). It is based on the mind, body, spirit, and community and supports the concept that healing is always possible, even when curing is not; IM is relationship-centered care requiring the active participation of the patient to become more self-aware, to think about their experiences of health and illness, to develop and maintain caring relationships, and to commit to effective communication with the healing team. An integrated treatment strategy to meet the integrative health care needs of the individual is then based on individual CAM therapies. The management of patients at the end of life is often managed through palliative care and acknowledges that dying is a normal part of life. Each healing journey of the mind, the body, and the spirit enriches the individual, the family, and the healing team.

Although pain management is central to pediatric chronic pancreatitis (CP) care, no evidence-based guidelines exist. In this scoping systematic review, we sought promising strategies for CP pain treatment in children. We systematically reviewed literature on pain management in children and adults with CP, and 2 conditions with similar pain courses: juvenile idiopathic arthritis and sickle cell disease. Of 8997 studies identified, 287 met inclusion criteria. There are no published studies of analgesic medications, antioxidants, dietary modification, integrative medicine, or regional nerve blocks in children with CP. In adults with CP, studies of nonopioid analgesics, pancreatic enzymes, and dietary interventions have mixed results. Retrospective studies suggest that endoscopic retrograde cholangiopancreatography and surgical procedures, most durably total pancreatectomy with islet autotransplant, improve pain for children with CP. Follow-up was short relative to a child's life. Large studies in adults also suggest benefit from endoscopic therapy and surgery, but lack conclusive evidence about optimal procedure or timing. Studies on other painful pediatric chronic illnesses revealed little generalizable to children with CP. No therapy had sufficient high-quality studies to warrant untempered, evidence-based support for use in children with CP. Multicenter studies are needed to identify pain management "best practices."