San Diego Study: Acupuncture Effective For Pain Management In Children After Tonsillectomy
December 9, 2013 1:38 p.m.
James Ochi, M.D., ENT specialist
Farshad, Ahadian, M.D., clinical professor, anesthesiology, medicaldDirector — Center for Pain Medicine, UC San Diego
Related Story: San Diego Study: Acupuncture Effective For Pain Management In Children After Tonsillectomy
ALISON ST. JOHN: For children having tonsils or adenoids removed is pretty painful surgery. But now the FDA has banned one of the most common drugs used to control the paint, codeine. A study published in an international Journal of pediatric medicine suggests an alternative kind of pain relief but does not involve administering any kind of strong pain medication at all. Although it does involve needles. Research shows acupuncture can significantly reduce pain for children after an operation. My guests are Dr. James Ochi who is author of the published study. Thank you so much for coming in Dr. Ochi.
JAMES OCHI: Thank you so much, Alison
ALISON ST. JOHN: And Dr. James Ochi is a pediatric ear nose and throat specialist in private practice with privileges at Rady's Children's Hospital. We also have in studio Dr. Farshad Ahadian. He's the medical director for the Center for pain management at UC San Diego. Welcome Doctor.
FARSHAD AHADIAN: Good morning.
ALISON ST. JOHN: So let's start with you Dr. Ochi, what about this ruling from the FDA tells what the FDA decided earlier this year by using codeine to control pain in children.
JAMES OCHI: Sure. The FDA had gotten what they call numerous reports of children having unfortunately died after this type of surgery and when they investigated the reason for this it turns out that these children had been metabolizing codeine in an ultra-rapid fashion so what ends up happening is codeine gets metabolized to morphine. And morphine although highly effective for pain relief carries with it a potential side effect for respiratory depression.
ALISON ST. JOHN: Well but it was pretty standard practice before the decision this year?
JAMES OCHI: Yes I've been a doctor for 29 years and I had been prescribing codeine or actually liquid Vicodin that whole time.
ALISON ST. JOHN: But had you seen any negative side effects?
JAMES OCHI: I had not seen any deaths, thank God, just the usual adverse side effects like nausea vomiting and constipation, but no deaths.
ALISON ST. JOHN: so on average when a child has been through surgery how long do they have to do with paint?
JAMES OCHI: Uniformly about 10 days and that's true no matter who does the surgery or how it is done.
ALISON ST. JOHN: So now as well as being a pediatric physician you are also trained as an acupuncturist, right? Why did you decide to try acupuncture as an alternative?
JAMES OCHI: Even when we could give codeine so many of the kids just did not get enough pain relief and I felt so awful for those children and especially for the parents, usually for the mother trying to take care of this child because she couldn't, typically the mothers would call and just be in despair because they could get their children to take their medicine or drink fluids.
ALISON ST. JOHN: That is distressing. So you decided to try acupuncture. Tell us how you went about the study. Did you have placebos? Did you have children that were and were not receiving acupuncture how did you go about doing research?
JAMES OCHI: What I did personally was over a three-month window I did 56 tonsillectomies. And of the 56 patients I invited all of them to come back to see me in the clinic if they have significant issues with pain during the recovery. 30 one of those patients came and had acupuncture. And so I simply and so the mother and child would come into the clinic could ask them to rate their pain from 0 to 10 and do acupuncture, and ask them to rate their pain again.
ALISON ST. JOHN: Okay we will ask you just a minute about how you got the children to submit to needles because that's not always automatic either, but Dr. Ahadian, tell us from your perspective how much of the challenges are to provide pain relief for children when they may react to drugs differently than adults.
FARSHAD AHADIAN: Absolutely. Providing pain relief in general postoperative can be a challenge. Struggled with it for many decades even for adults. Children probably pose special challenges. Prematurity age can be a challenge comorbidities such as premature nervous system, those developmental
ALISON ST. JOHN: What does it mean
FARSHAD AHADIAN: Developmental delays were children may not be fully developed their central nervous system may not be fully developed so they might be much more prone to the side effects that Dr. Ochi is talking about such as respiratory depression for example. Other comorbidities other medical problems that might make them more debilitated or ill or sick again so they might be more prone to the side effects from medications. So those are some of the major complications.
ALISON ST. JOHN: Were you surprised by the FDA's decision earlier this year
FARSHAD AHADIAN: That seems to me only a small part of what is actually going on. I think nationwide in the US the magnifying glass is on over use of opioids. You know, for adults, because of social purposes, addiction, substance abuse, but also a lot of increased deaths, 3 to 4 fold increase death rates. From opioids. And I suspect that has something to do with putting this even closer on the FDA's radar. So I can't say that I'm totally surprised.
ALISON ST. JOHN: but it is part of a growing challenge really for your profession and how to deal with the bearing in mind the side effects of some of these very strong pain medications. So Dr. Ochi how did you get young children to say yes to having needles stuck into them which is essentially what acupuncture is?
JAMES OCHI: That's exactly right. Well, what I did was I would show the patient's vein needle and I would say to them this is a needle. And this is my hand. Then I would simply take the needle in. To the hilt in my hand. In front of the child. And I would say to them, see, this is not an owie. Because I did this to myself. And I want to see if we can help you.
ALISON ST. JOHN: They would see that there is no blood.
JAMES OCHI: And I wasn't crying or screaming and children a very practically oriented I think.
ALISON ST. JOHN: What do the parents say when you initially suggest it to them, are they all up for it?
JAMES OCHI: I think when a mother is dealing with a child in pain she's quite happy to take suggestions.
ALISON ST. JOHN: That's right. That's very true, right even if they've never tried acupuncture themselves they were open to it. Now you can just you after the surgery did you tell us about how you used it.
JAMES OCHI: In this study it was being used after the surgery. But obviously, the next phase and the next part of this would be to try to come up with strategies that could be done during the surgery. In an effort to try to prevent the child from suffering significantly altogether.
ALISON ST. JOHN: Interesting. Tell us again how acupuncture actually works.
JAMES OCHI: Well, there are many theories from a basic site standpoint. But, the ancient Chinese observed that the flow of energy, or Chi. You are trying to rebuild such after surgery
ALISON ST. JOHN: there are a number of uses for acupuncture especially back pain I understand.
JAMES OCHI: Back pain is the number one reason why people seek out of the country
ALISON ST. JOHN: But is yours the first research in terms of children using after tonsillectomies and having their adenoids out?
JAMES OCHI: There are other articles that speak to this issue but to my knowledge this is the first of that's been done after the ban on codeine, because that was February of this year.
ALISON ST. JOHN: Right. Does seem like there are more Americans interested in using acupuncture and apparently there was a survey five years ago that showed 3 million Americans had used acupuncture in the past year and gains some benefit so there's probably even more than that now. Do you feel like this is actually something that will be easy to convince people is an effective way to treat pain after a tonsillectomy?
JAMES OCHI: Well yes in the sense that I've kept track of numbers and fully 96% of my patients who are offered acupuncture up for it with their child. For surgery.
ALISON ST. JOHN: The parents do as well?
JAMES OCHI: What I mean as well what I mean is fully 96% of parents will consent to that.
ALISON ST. JOHN: Okay now, Dr. Ahadian, is there a process you're going through when deciding how to treat pain what kind of things might you consider and that when might you consider acupuncture?
FARSHAD AHADIAN: Gosh I think they early for analgesia in a way is a continuum. Under one extreme we can have the most conservative things may be starting with self-care, respects, heating pads, massage, things like that. As we go up in the level of pain and severity of the symptoms we may think about using simple analgesics. Mixed analgesics perhaps very mild opioids mixed with anti-inflammatories or acetaminophen. As we go again higher and higher may be starting to use more potent opioids. Even more severe postoperative pain we may consider things like patient controlled analgesia. Epidural analgesia.
ALISON ST. JOHN: That's when you inject somebody's spine, is that right?
FARSHAD AHADIAN: That's right so it's very much in analogous to a labor analgesia, placing a small catheter in the spine and administering medication there. And so on and so forth and probably the next level up would be what's called continuous regional anesthesia techniques where we place the catheter along the nerve and provide analgesia in that manner. I think acupuncture nicely fits in, I would say anywhere along the continuum because besides the fact that it's a continual we also need to utilize these different modalities to combine them together whenever is necessary. In my practice I find actually combining these conventional therapies with acupuncture for example makes me much more effective and provides much higher level of satisfaction for patients compared to using a single agent.
ALISON ST. JOHN: So it could, acupuncture could be effective when combined with other treatments, even if the pain is very severe? All the way along the continuum.
FARSHAD AHADIAN: Absolutely. And I think acupuncture has other if you will, fringe benefits. Besides providing analgesia, or pain relief, it can for example reduce postoperative nausea and vomiting. Or, it might have an opioid sparing effect, reduce the overall dose of opioids so that the patient my recovery from anesthesia much quicker. You know, and be discharged from the recovery room in the hospital much earlier. So it may even have medical economic advantages.
ALISON ST. JOHN: It is interesting that you could actually administer the needles even before the surgery and then have them come out with less pain so they don't have to go through even the very acute pain because it's pretty painful isn't it, tonsillitis for child?
JAMES OCHI: It is, it can be very painful.
ALISON ST. JOHN: how do you get the child to describe their level of pain because it's quite difficult even for a did an adult to know how to describing.
JAMES OCHI: Well, there's something called a visual analog scale that's been verified and validated and essentially it is a series of faces that go more or less from a happy face to an extremely unhappy face. So that is correlated with the usual skin of 0 to 10, and other [inaudible] show up to the emergency room with pain they often say what is your level of being 0 to 10 for an adult and adult may say six or seven and a child might point to the face that correlates with six or seven.
ALISON ST. JOHN: As a result of the acupuncture how much do they change the face that they go to?
JAMES OCHI: Not in my study on average the 30 one patients reported a level of 5.5. In other words it between five and 6/10 points when they showed up to the clinic after the surgery. After about 15 min. of acupuncture the same level of pain and fell to 2.0.
ALISON ST. JOHN: Interesting and do they come back for acupuncture sessions regularly for the several days that it takes for the pain to go away?
JAMES OCHI: They can. Although I pulled the patients looking for acupuncture and on average they benefited from it for 2 ½ days. So many times, by the time the 2 ½ days were up the mothers would say to me you know I think Tylenol is fine now, just plain Tylenol.
ALISON ST. JOHN: And the FDA hasn't said anything about Tylenol?
JAMES OCHI: Not as of yet.
ALISON ST. JOHN: So Dr. Ahadian, you have a challenge sure you have to discover new ways to just control pain are there other ways coming from Eastern philosophies in medicine your professional is able to use in controlling pain to get away from the damaging pain control medications?
FARSHAD AHADIAN: Well, Dr. Ochi and I were actually talking before we came in here and I think there's probably extensive ways of utilizing the medical acupuncture. I think preoperative administration, pretreatment might go a long way is not only to reducing the anesthetic requirements and speeding up the recovery of the patient, sort of prime somebody you know, earlier we talked about mechanism of action of acupuncture and Dr. Ochi very nicely described you know how the ancient Chinese thought about it but there's a lot of research in conventional medicine that says that acupuncture causes release of endorphins. Your own intrinsic pain relieving substance sort of morphine like substances. There are other mechanism of action with other altering of other neurotransmitters that will cause with, it's more repeated treatment so it may be that pretreatment combined with some post treatment might be a more effective way of providing analgesia.
ALISON ST. JOHN: Are they open to all of this at Children's Hospital Dr. Ochi?
JAMES OCHI: I'm happy to tell you Rady Children's has been very supportive of my efforts to do acupuncture the operating room and I'm very grateful to them for that.
ALISON ST. JOHN: Would you say similar regional hospitals have acceptances for acupuncture
JAMES OCHI: It varies as I have found
ALISON ST. JOHN: Insurance companies have been providing coverage for certain number of acupuncture sessions over a year for a long time now rate do you feel like perhaps of what Dr. Ahadian, the FDA's decision you were saying about the FDA's decision about codeine, is it possible that acupuncture may play a more important role even for insurers?
FARSHAD AHADIAN: I think acupuncture has been assuming a more extensive role in the US in convention, and worldwide. I think when I first started at UCSD about almost 14 years ago as you said, almost no insurance coverage for it. In the last several years I can tell you that as you say, patients, and and they have several visits approved by the insurance companies. I can tell you that there are numerous hospitals around the nation that routinely corporate acupuncture in various situations. The operating room inpatient unit, pediatric and so on and so forth and so I think it's going to continue to escalate.
ALISON ST. JOHN: Are there other doctors that perform acupuncture for children going in for tonsillectomies?
JAMES OCHI: According to the American Academy for medical acupuncture there are only two doctors in a particular specialty of your nose and throat trained acupuncture myself and a gentleman in Chicago. So, not really.
ALISON ST. JOHN: It is still early stages.
JAMES OCHI: It is.
ALISON ST. JOHN: For people are really curious about where you would put the needles and to stimulate the ingredients for a tonsillectomy, can you describe the places, the parts on the face or the party.
JAMES OCHI: I can also but the article is available via open access on the web in other words you don't have to pay to get access to the access to the article that I published.
ALISON ST. JOHN: Good. We will have a link to that on our KPBS website.
JAMES OCHI: To answer your question the points are primarily on the head and the upper limbs, the arms.
ALISON ST. JOHN: the arms, what would that be, how did the meridians connect to the throat?
JAMES OCHI: It happens to be that one of the most potent points is located right between your thumb and index finger.
ALISON ST. JOHN: Yes I have seen that particular point pointed out before.
JAMES OCHI: That's on pretty and that starts at the tip of your index finger and runs up along your arm, up your shoulder into the back end dives deep into the throat where the tonsils live and your nose and ends up on the other side of the nose, so in other words you're taking advantage of the fact that this point in your hand has a very direct connection to the area of your throat.
ALISON ST. JOHN: That's a good tip. I know I've used it before. That's little place between your index finger and your thumb and if you squeeze it, you don't even need any help.
JAMES OCHI: That's right
ALISON ST. JOHN: That can affect pain. Very interesting. I'd like to thank you both for joining me I guests have been talking about alternative modes of pain treatment especially in children, Dr. James Ochi is the author of the published study think is much for joining us and also Dr. Farshad thank you for being with us.
FARSHAD AHADIAN: Thank you Alison
JAMES OCHI: Thank you so much for having me.