Use of Complementary Health Approaches Overall and for Pain Management by US Adults

This study examines prevalence of use of complementary health approaches overall and for pain management among US adults.

Chronic pain among U.S. sexual minority adults who identify as gay, lesbian, bisexual, or "something else"

ABSTRACT

This study assesses chronic pain prevalence among sexual minority U.S. adults who self-identify as gay/lesbian, bisexual, or "something else," and examines the role of select covariates in the observed patterns. Analyses are based on 2013 to 2018 waves of the National Health Interview Survey, a leading cross-sectional survey representative of the U.S. population. General chronic pain and chronic pain in 3+ sites among adults aged 18 to 64 years (N = 134,266 and 95,675, respectively) are analyzed using robust Poisson regression and nonlinear decomposition; covariates include demographic, socioeconomic, healthcare, and psychological distress measures. We find large disparities for both pain outcomes. Americans who self-identify as bisexual or "something else" have the highest general chronic pain prevalence (23.7% and 27.0%, respectively), compared with 21.7% among gay/lesbian and 17.2% straight adults. For pain in 3+ sites, disparities are even larger: Age-adjusted prevalence is over twice as high among adults who self-identify as bisexual or "something else" and 50% higher among gay/lesbian, compared with straight adults. Psychological distress is the most salient correlate of the disparities, whereas socioeconomic status and healthcare variables explain only a modest proportion. Findings thus indicate that even in an era of meaningful social and political advances, sexual minority American adults have significantly more chronic pain than their straight counterparts. We call for data collection efforts to include information on perceived discrimination, prejudice, and stigma as potential key upstream factors that drive pain disparities among members of these minoritized groups.

Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020

Importance

Chronic pain risk and prognosis estimates are needed to inform effective interventions.

Objective

To estimate rates of chronic pain and high-impact chronic pain (HICP) incidence and persistence in US adults across demographic groups.

Design, Setting, and Participants

This cohort study examined a nationally representative cohort with 1 year of follow-up (mean [SD], 1.3 [0.3] years). Data from the 2019-2020 National Health Interview Survey (NHIS) Longitudinal Cohort were used to assess the incidence rates of chronic pain across demographic groups. The cohort was created using random cluster probability sampling of noninstitutionalized civilian US adults 18 years or older in 2019. Of 21 161 baseline participants in the 2019 NHIS who were randomly chosen for follow-up, 1746 were excluded due to proxy response(s) or lack of contact information, and 334 were deceased or institutionalized. Of the 19 081 remaining, the final analytic sample of 10 415 adults also participated in the 2020 NHIS. Data were analyzed from January 2022 to March 2023.

Exposures

Self-reported baseline sex, race, ethnicity, age, and college attainment.

Main Outcomes and Measures

Primary outcomes were the incidence rates of chronic pain and HICP, and secondary outcomes were the demographic characteristics and rates across demographic groups. A validated measure of pain status ("In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?") yielded 3 discrete categories each year: pain free, nonchronic pain, or chronic pain (pain "most days" or "every day"). Chronic pain present in both survey years was considered persistent; HICP was defined as chronic pain that limited life or work activities on most days or every day. Rates were reported per 1000 person-years (PY) of follow-up, and age standardized based on the 2010 US adult population.

Results

Among 10 415 participants included in the analytic sample, 51.7% (95% CI, 50.3%-53.1%) were female, 54.0% (95% CI, 52.4%-55.5%) were aged 18 to 49 years, 72.6% (95% CI, 70.7%-74.6%) were White, 84.5% (95% CI, 81.6%-85.3%) were non-Hispanic or non-Latino, and 70.5% (95% CI, 69.1%-71.9%) were not college graduates. Among pain-free adults in 2019, incidence rates of chronic pain and HICP in 2020 were 52.4 (95% CI, 44.9-59.9) and 12.0 (95% CI, 8.2-15.8) cases per 1000 PY, respectively. The rates of persistent chronic pain and persistent HICP in 2020 were 462.0 (95% CI, 439.7-484.3) and 361.2 (95% CI, 265.6-456.8) cases per 1000 PY, respectively.

Conclusions and Relevance

In this cohort study, the incidence of chronic pain was high compared with other chronic diseases. These results emphasize the high disease burden of chronic pain in the US adult population and the need for early management of pain before it becomes chronic.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability. PERSPECTIVE: We evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.

Cross-Sectional Analyses of High-Impact Pain Across Pregnancy Status by Race and Ethnicity

Background: Preclinical and clinical research has suggested the existence of pregnancy-associated analgesia, wherein responses to painful stimulation or pain from disease decrease during pregnancy. Materials and Methods: We combined data from multiple years (2012-2015) of the National Health Interview Survey to examine high-impact pain by Hispanic ethnicity and race in women with no prior pregnancy, during pregnancy, and previously pregnant. Results: High-impact pain was less common for women during pregnancy (10.3%; 95% confidence interval [CI]: 7.0%-13.7%) than it was for women who had never been pregnant (13.7%; 95% CI: 12.8%-14.5%) and for women who had previously been pregnant (19.8%; 95% CI: 16.0%-23.7%). However, when we examined the data by Hispanic ethnicity and race, we found that non-Hispanic White (NHW) women were less likely to report high-impact pain during pregnancy, but non-Hispanic Black (NHB) women and Hispanic White women were not. In women who reported no prior pregnancy, NHW women were most likely to report high-impact pain, followed by NHB women and Hispanic women. In post hoc analyses, we found that while menstrual problems were associated with increased odds of having high-impact pain, an interaction was not observed between menstrual problems and race/ethnicity (p = 0.48). Conclusions: This cross-sectional study presents a nationally representative examination of the prevalence of high-impact pain across pregnancy status. Using a nationally representative sample of women, we have demonstrated that the prevalence of high-impact pain varies across pregnancy status and that race/ethnicity and the presence of menstrual problems independently affect this prevalence.

A Review of Potential National Chronic Pain Surveillance Systems in the United States

Pain has been established as a major public health problem in the United States (U.S.) with 50 million adults experiencing chronic pain and 20 million afflicted with high-impact chronic pain (ie, chronic pain that interferes with life or work activities). High financial and social costs are associated with chronic pain. Over the past 2 decades, pain management has been complicated by the marked increase in opioids prescribed to treat chronic noncancer pain and by the concurrent opioid crisis. Monitoring the prevalence of chronic pain and pain management is especially important because pain management is changing in uncertain ways. We review potential U.S. chronic pain surveillance systems, present potential difficulties of chronic pain surveillance, and explore how to address chronic pain surveillance in the current opioid era. We consider case definitions, severity, anatomic site, and varieties of chronic pain management strategies in reviewing and evaluating national surveys for chronic pain surveillance. Based on the criteria evaluated, the National Health Interview Survey offers the best single source for pain surveillance as the pain-related questions administered are brief, valid, and cover a broad scope of pain-related phenomena. PERSPECTIVE: This review article describes data sources that can be leveraged to conduct national chronic pain surveillance in the United States, explores case defining or pain-related questions administered, and evaluates them against 8 surveillance attributes.

Reasons Office-Based Physicians in the United States Recommend Common Complementary Health Approaches to Patients: An Exploratory Study Using a National Survey

Objective: To examine the reasons why office-based physicians do or do not recommend four selected complementary health approaches to their patients in the context of the Andersen Behavioral Model. Design: Descriptive estimates of physician-level data from the 2012 National Ambulatory Medical Care Survey (NAMCS) Physician Induction Interview, a nationally representative survey of office-based physicians (N = 5622, weighted response rate = 59.7%). Setting/Location: The United States. Outcome measures: Reasons for the recommendation or lack thereof to patients for: herbs and other non-vitamin supplements, chiropractic/osteopathic manipulation, acupuncture, and mind-body therapies (including meditation, guided imagery, and progressive relaxation). Differences by physician sex and medical specialty were described. Results: For each of the four complementary health approaches, more than half of the physicians who made recommendations indicated that they were influenced by scientific evidence in peer-reviewed journals (ranging from 52.0% for chiropractic/osteopathic manipulation [95% confidence interval, CI = 47.6-56.3] to 71.3% for herbs and other non-vitamin supplements [95% CI = 66.9-75.4]). More than 60% of all physicians recommended each of the four complementary health approaches because of patient requests. A higher percentage of female physicians reported evidence in peer-reviewed journals as a rationale for recommending herbs and non-vitamin supplements or chiropractic/osteopathic manipulation when compared with male physicians (herbs and non-vitamin supplements: 78.8% [95% CI = 72.4-84.3] vs. 66.6% [95% CI = 60.8-72.2]; chiropractic/osteopathic manipulation: 62.3% [95% CI = 54.7-69.4] vs. 47.5% [95% CI = 42.3-52.7]). For each of the four complementary health approaches, a lack of perceived benefit was the most frequently reported reason by both sexes for not recommending. Lack of information sources was reported more often by female versus male physicians as a reason to not recommend herbs and non-vitamin supplements (31.4% [95% CI = 26.8-36.3] vs. 23.4% [95% CI = 21.0-25.9]). Conclusions: There are limited nationally representative data on the reasons as to why office-based physicians decide to recommend complementary health approaches to patients. Developing a more nuanced understanding of influencing factors in physicians' decision making regarding complementary health approaches may better inform researchers and educators, and aid physicians in making evidence-based recommendations for patients.

Physician Office Visits That Included Complementary Health Approaches in U.S. Adults: 2005-2015

Introduction: The Institute of Medicine has described the need for comparing models of care delivery involving complementary health approaches and conventional medical practitioners. As a step toward addressing this need, we used a nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided. Methods: NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. We examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for health visit. We ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide development of logistic regression models. Results: Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem. Conclusion: We present an overview of the first study of office-based physician visits where complementary health approaches were recommended or ordered to their patients. These data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

National Estimates of Chronic Musculoskeletal Pain and Its Treatment in Children, Adolescents, and Young Adults in the United States: Data From the 2007-2015 National Ambulatory Medical Care Survey

OBJECTIVES

To portray physician office visits by young Americans with chronic musculoskeletal pain; to describe clinical management in this group; and to explore factors associated with prescribed treatments.

STUDY DESIGN

Using nationally representative data of ambulatory physician office visits (2007-2015 United States National Ambulatory Medical Care Survey), we identified and cross-sectionally analyzed visits by persons <25 years of age diagnosed with a chronic musculoskeletal pain condition.

RESULTS

There were 28.6 million visits over the 9-year period for chronic musculoskeletal pain for persons <25 years of age, (average 3.2 million visits/year). There were more visits among older age groups, female persons, non-Hispanic White ethnicity/race, and those with more medical visits in the past year. Nonopioid medications were the most frequent treatments in all age groups (range 38.5%-48.8%). Opioids were rarely prescribed for children and adolescents but were prescribed in 23% of visits among young adults (18-24 years of age). Health education and counseling were consistently prescribed at 20% of visits and physical therapy (range 9.5%-23.7%) and other treatments were less frequently prescribed. Age, sex, payment source, and physician specialty were associated with various treatments.

CONCLUSION

There were over 3 million annual visits for chronic musculoskeletal pain in young Americans; these increased with age. Pharmacologic treatment is used more than nonpharmacologic approaches, and opioid prescribing in the 18- to 24-year-old age group approaches estimates in adults with musculoskeletal pain.

Longitudinal Analysis of Complementary Health Approaches in Adults Aged 25-74 Years from the Midlife in the U.S. Survey Sample

Objectives: Complementary health approaches include herbal products and mind-body practices. Several studies have identified predictors for complementary health approach use, yet there are two gaps: (1) How does use change? (2) Do factors associated with use influence this change over time? Using the Midlife in the United States (MIDUS), we examined how sociodemographic factors affected use longitudinally, and whether these associations differed between new and continued/discontinued use of herbal products, meditation, chiropractic, and massage therapy. Design: MIDUS is a national probability sample of adults aged 25 or older that has collected more than 20 years of longitudinal data, including the use of complementary health approaches. We employed the Andersen Model as a framework to identify predisposing, enabling, and health need factors associated with complementary health approach use based on previously identified and hypothesized factors. We ran Chi-square analyses to first test bivariate associations between our independent variables and four modalities to further guide logistic regression models. Results: Each of the four approaches examined saw substantial increases in prevalent use. However, only about 25% to 38% of individuals continued use from one wave to the next, whereas only 2%-9% of individuals who did not use a given approach in a wave reported use in the subsequent wave. Age, spiritual importance, and previous wave one use were all significantly associated with new use across all four modalities. Previous wave one use was associated with continued/discontinued use for all modalities. Age and education were significantly associated with discontinued use of chiropractic. Conclusion: We present the first longitudinal analysis of complementary health approaches in a nationally representative sample. These data distinguish between new and continued/discontinued use of complementary health approaches over time and provide insights into the interpretation of complementary health approach prevalence data, as well as important predictors of use.

Pain Prevalence, Chronicity and Impact Within Subpopulations Based on Both Hispanic Ancestry and Race: United States, 2010-2017

We provide national surveillance estimates of pain chronicity, severity and impact in adult subpopulations defined by both Hispanic Ancestry and Race. Data are from 144,434 adults who completed validated questionnaires in the 2010-2017 National Health Interview Survey asking about pain status within the last 3 (N = 84,664) or 6 months (N = 59,770). Multivariable logistic regression was used to assess the relationship between pain and ethnicity/race. Compared to White Puerto Rican participants, White participants with Central/South American and Mexican ancestry had reduced odds of reporting Category 3-4 pain and High-Impact Chronic Pain (HICP), while those of Cuban ancestry had reduced odds of only HICP - eg, White participants with Mexican ancestry had 32% lower odds of having Category 3-4 pain and 50% lower odds of having HICP. While no differences were seen between White Puerto Rican and White Non-Hispanic participants for Category 3-4 pain, White Non-Hispanics had 40% lower odds of reporting HICP. Asian Non-Hispanic and Black Non-Hispanic participants had significantly lower odds of reporting Category 3-4 pain and HICP compared to White Puerto Rican participants, eg, Black Non-Hispanic participants had 26% lower odds off having Category 3-4 pain and 42% lower odds of having HICP. Perspective: By examining pain status in discrete demographic groups based on Hispanic Ancestry and Race, this report further documents substantial difference in health status among underserved populations and provides a baseline for continuing surveillance research on pain, with the eventual goal of eliminating disparities in pain assessment and treatment.

Possible differential benefits of edetate disodium in post-myocardial infarction patients with diabetes treated with different hypoglycemic strategies in the Trial to Assess Chelation Therapy (TACT)

BACKGROUND

The NIH-funded Trial to Assess Chelation Therapy (TACT) randomized 1708 stable patients age ≥50 who were ≥6 months post myocardial infarction to 40 infusions of an edetate disodium-based regimen or placebo. In 633 patients with diabetes, edetate disodium significantly reduced the primary composite endpoint of mortality, recurrent myocardial infarction, stroke, coronary revascularization, or hospitalization for angina (hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.44-0.79, p < 0.001). The principal secondary endpoint of a composite of cardiovascular death, myocardial infarction, or stroke was also reduced (HR 0.60, 95% CI 0.39-0.91, p = 0.017). It is unknown if the treatment effect differs by diabetes therapy.

METHODS

We grouped the subset of 633 patients with diabetes according to glucose-lowering therapy at time of randomization. The log-rank test was used to compare active therapy versus placebo. All treatment comparisons were performed using 2-sided significance tests at the significance level of 0.05 and were as randomized. Relative risks were expressed as HR with associated 95% CI, calculated using the Cox proportional hazards model.

RESULTS

There were 162 (25.7%) patients treated with insulin; 301 (47.5%) with oral hypoglycemics only; and 170 (26.8%) receiving no pharmacologic treatment for diabetes. Patients on insulin reached the primary endpoint more frequently than patients on no pharmacologic treatment [61 (38%) vs 49 (29%) (HR 1.56, 95% CI 1.07-2.27, p = 0.022)] or oral hypoglycemics [61 (38%) vs 87 (29%) (HR 1.46, 1.05-2.03, p = 0.024)]. The primary endpoint occurred less frequently with edetate disodium based therapy versus placebo in patients on insulin [19 (26%) vs 42 (48%) (HR 0.42, 95% CI 0.25-0.74, log-rank p = 0.002)], marginally in patients on oral hypoglycemics [38 (25%) vs 49 (34%) (HR 0.66, 95% CI 0.43-1.01, log-rank p = 0.041)], and no significant difference in patients not treated with a pharmacologic therapy [23 (25%) vs 26 (34%) (HR 0.69, 95% CI 0.39-1.20, log-rank p = 0.225)]. The interaction between randomized intravenous treatment and type of diabetes therapy was not statistically significant (p = 0.203).

CONCLUSIONS

Edetate disodium treatment in stable, post-myocardial infarction patients with diabetes suggests that patients on insulin therapy at baseline may accrue the greatest benefit.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov identifier: http://clinicaltrials.gov/ct2/show/NCT00044213?term=TACT&rank=7 identifier Trial to Assess Chelation Therapy (TACT), NCT00044213.

Differential Outcomes With Edetate Disodium-Based Treatment Among Stable Post Anterior vs. Non-Anterior Myocardial Infarction Patients

BACKGROUND

The Trial to Assess Chelation Therapy (TACT) found that chelation therapy significantly reduced clinical events in patients with a history of myocardial infarction (MI). The initial report of TACT included the observation of an interaction between edetate disodium infusions and MI location, as well as diabetes. Thus, we examined in greater detail the effect of edetate disodium chelation therapy as a function of MI location and diabetes.

METHODS

Patients (n = 1708) at least 6 weeks post-MI and age ≥ 50 were randomized to receive 40 infusions of a 500 mL chelation solution or placebo (median follow-up 55 months). The effect of edetate disodium on the primary outcome (all-cause mortality, MI, stroke, hospitalization for angina, or coronary revascularization) was assessed as a function of MI location using log-rank test and Cox regression model, adjusting for other prognostic variables.

RESULTS

Among patients with post anterior MI (n = 674), chelation was associated with a lower risk of the primary endpoint (HR 0.63, 95% CI 0.47-0.86, p = 0.003) among anterior MI patients, but not in post non-anterior MI (n = 1034) patients (HR 0.96, 95% CI 0.77-1.20, p = 0.702) (p-for-interaction = 0.032). The point estimates for each component of the primary endpoint favored chelation therapy. The differing treatment effect in patients with post anterior vs. non-anterior MI was consistent among patients with or without diabetes and remained significant after adjusting for other prognostic variables (p < 0.01).

CONCLUSIONS

Edetate disodium infusions reduced the risk of cardiovascular events among patients with a prior anterior MI. Future studies should focus on replicating these results and understanding the mechanisms of benefit.

Alcohol Consumption and Risk of Dementia and Cognitive Decline Among Older Adults With or Without Mild Cognitive Impairment

IMPORTANCE

Substantial heterogeneity and uncertainty exist in the observed associations between alcohol consumption and dementia.

OBJECTIVE

To assess the association between alcohol consumption and dementia and the roles of mild cognitive impairment (MCI) and apolipoprotein E ε4 (APOE E4) genotype in modifying this association.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Ginkgo Evaluation of Memory Study, conducted from 2000 to 2008 among US community-dwelling participants. This study analyzed 3021 participants aged 72 years and older who were free of dementia. Data analysis was performed from 2017 to 2018.

EXPOSURES

Self-reported alcohol consumption, drinking frequency, and quantity.

MAIN OUTCOMES AND MEASURES

Using multivariable proportional hazards regression and linear mixed models, the risk of dementia and the rate of change over time in the Modified Mini-Mental State Examination were estimated.

RESULTS

Among 3021 participants, the median (interquartile range) age was 78 (76-80) years; 1395 (46.2%) were female. During a median (interquartile range) follow-up of 6.0 (4.9-6.5) years, 512 cases of dementia occurred. For 7.1 to 14.0 drinks per week compared with less than 1.0 drink per week, the hazard ratios for dementia were 0.63 (95% CI, 0.38-1.06) among 2548 participants without MCI and 0.93 (95% CI, 0.47-1.84) among 473 participants with MCI. Among participants with MCI, the hazard ratio for dementia was 1.72 (95% CI, 0.87-3.40) for more than 14.0 drinks per week compared with less than 1.0 drink per week. The association of alcohol intake with dementia differed for participants with and without baseline MCI (P for interaction = .03). Among participants without MCI, daily low-quantity drinking was associated with lower dementia risk than infrequent higher-quantity drinking (hazard ratio, 0.45; 95% CI, 0.23-0.89; P = .02). Findings were consistent when stratified by sex, age, and APOE E4 genotype. Compared with drinking less than 1.0 drink per week, complete abstention (in participants without MCI) and the consumption of more than 14.0 drinks per week (in participants with MCI) were associated with lower Modified Mini-Mental State Examination scores (mean difference at follow-up compared with baseline, -0.46 point [95% CI, -0.87 to -0.04 point] and -3.51 points [95% CI, -5.75 to -1.27 points], respectively).

CONCLUSIONS AND RELEVANCE

In this study, complete abstention and consuming more than 14.0 drinks per week (compared with drinking <1.0 drink per week) were associated with lower cognitive scores among participants aged 72 years and older. Particular caution is needed among individuals with MCI who continue to drink alcohol.

Eighteen-Year Trends in the Prevalence of, and Health Care Use for, Noncancer Pain in the United States: Data from the Medical Expenditure Panel Survey

We used data from the nationally representative Medical Expenditure Panel Survey to determine the 18-year trends in the overall rates of noncancer pain prevalence and pain-related interference, as well as in health care use attributable directly to pain management. The proportion of adults reporting painful health condition(s) increased from 32.9% (99.7% confidence interval [CI] = 31.6-34.2%;120 million adults) in 1997/1998 to 41.0% (99.7% CI = 39.2-42.4%; 178 million adults) in 2013/2014 (P_trend < .0001). Among adults with severe pain-related interference associated with their painful health condition(s), the use of strong opioids specifically for pain management more than doubled from 11.5% (99.7% CI = 9.6-13.4%) in 2001/2002 to 24.3% (99.7% CI = 21.3-27.3%) in 2013/2014 (P_trend < .0001). A smaller increase (P_interaction < .0001) in strong opioid use was seen in those with minimal pain-related interference: 1.2% (99.7% CI = 1.0-1.4%) in 2001/2002 to 2.3% (99.7% CI = 1.9-2.7%) in 2013/2014. Small but statistically significant decreases (P_trend < .0001) were seen in 1) the percentage of adults with painful health condition(s) who had ≥1 ambulatory office visit for their pain: 56.1% (99.7% CI = 54.2-58.0%) in 1997/1998 and 53.3% (99.7% CI = 51.4-55.4%) in 2013/2014; 2) the percentage who had ≥1 emergency room visit for their pain; 9.9% (99.7% CI = 8.6-11.2%) to 8.8% (99.7% CI = 7.9-9.7%); and 3) the percentage with ≥1 overnight hospitalization for their pain: 3.2% (99.7% CI = 2.6-4.0%) to 2.3% (99.7% CI = 1.8-2.8%). PERSPECTIVE: Our data illustrate changes in the management of painful health conditions over the last 2 decades in the United States. Strong opioid use remains high, especially in those with severe pain-related interference. Additional education of health care providers and the public concerning the risk/benefit ratio of opioids appears warranted.

Use of Yoga, Meditation, and Chiropractors Among U.S. Children Aged 4-17 Years

Yoga, meditation, and use of chiropractors are types of complementary health approaches developed outside of mainstream Western medicine (1-2). Although complementary health approaches as a whole are not widely used among children, previous work has established a rise in the use of selected approaches over time (3). This report presents the most recent national estimates of use of the three most prevalent approaches during the past 12 months, among children aged 4-17 years in the United States. Comparable estimates from 2012 are also included to examine changes over time.

Use of Yoga, Meditation, and Chiropractors Among U.S. Adults Aged 18 and Over

Complementary health is the use of holistic or unconventional medicine with mainstream Western medicine for health and wellness (1,2). Past research has identified yoga, meditation, and seeing a chiropractor as some of the most commonly used approaches (3). This report examines changes over time in the percentage of adults who used yoga, meditation, and chiropractors in the past 12 months, as well as variation by sex, age, and race and Hispanic origin.

Fibromyalgia patients and healthy volunteers express difficulties and variability in rating experimental pain: a qualitative study

Background and aims Despite the enormous body of literature spanning more than 50 years describing results of pain experiments, very few have used qualitative methods to explore subjects' thoughts while scoring experimental painful stimuli, and none in the available literature have used qualitative interviews to do so. The current study examined how participants in experimental pain research delineate pain ratings to better understand the unique influences of the experimental setting on pain scores. An additional aim was to highlight how individuals with fibromyalgia and healthy volunteers are differently influenced by characteristics of the experimental setting. Methods This was an inductive, qualitative study in which individual, semi-structured interviews were performed with 31 fibromyalgia patients and 44 healthy volunteers. Participants had taken part in a pain experiment during which a thermode was used to induce painful heat stimuli on two skin areas. There were two primary interview questions analyzed for this report: (1) "Thinking back to when you were getting the heat pain on your leg, what were you thinking about when deciding on your pain score?" and (2) Participants who said that it was difficult to decide on a pain score were asked to, "Describe what made it difficult to choose a number." Thematic analysis was used to generate conceptual categories from textual data and find common themes. Results Three notable differences were found between fibromyalgia patients and healthy volunteers: (1) using current daily pain as a benchmark was seen more in patients, (2) wanting to appear strong in front of the study investigators was more common in healthy volunteers, and (3) becoming mentally fatigued from rating many stimuli was more common for fibromyalgia patients. Thoughts while scoring pain included: (1) comparing with previous or current pain, (2) self-monitoring of one's ability to endure the pain, (3) focusing on the physical aspects of the pain, (4) knowing the experimental setting is safe, (5) focusing on the pain scale as an anchor, and (6) desire to appear strong. Additionally, five difficulties in scoring experimental pain were identified: (1) falling asleep, (2) mentally fatigued, (3) feeling as though they were guessing, (4) having to make a quick decision, and (5) difficulty in being consistent. Conclusions This study provides insights into the thoughts of participants in experimental pain research studies. Participants were distracted and influenced by the experimental setting and some factors differed for fibromyalgia patients versus healthy volunteers. Implications Understanding the ways in which the experimental setting influences pain ratings may help pain researchers better design and interpret studies. Researchers can use these findings to mitigate difficulties for participants in experimental research to add to its validity.

Prevalence and Pharmaceutical Treatment of Plantar Fasciitis in United States Adults

This study provides prevalence estimates of plantar fasciitis in U.S. adults, as well as the types and frequencies of pharmaceutical treatment specifically for this pain. Data are from the 2013 National Health and Wellness Survey, a large (n = 75,000) internet panel survey designed to approximate the adult U.S.

POPULATION

Strengths of associations are determined using multivariable logistic regression. It was estimated that .85% (95% confidence interval [CI] = .77-.92) of the sample reported diagnosed plantar fasciitis with pain in the past month. Higher prevalence of plantar fasciitis was seen in women (1.19%; referent) versus men (.47%), in those aged 45 to 64 (1.33%) versus those aged 18 to 44 (.53%; referent) years, and in the obese (1.48%) versus those with a body mass <25 (.29%; referent). Prescription medications for pain were used by 41.04% of plantar fasciitis respondents, but only 6.31% attributed this use specifically to plantar fasciitis pain. Nonsteroidal anti-inflammatory drugs (4.01%) and opioids (2.21%) were the most prevalent prescription drugs used specifically for plantar fasciitis pain. Almost 70% of individuals with plantar fasciitis used over the counter (OTC) analgesics for general pain management, with OTC nonsteroidal anti-inflammatory drugs being used by 49.47% and acetaminophen by 26.93% of respondents. Individuals diagnosed by medical specialists had twice the odds of using prescription drugs as those diagnosed by other providers (odds ratio = 2.12; 95% CI = 1.01-4.46). Non-Hispanic black individuals were more likely to use prescription pain medications specifically for plantar fasciitis pain than non-Hispanic white individuals (odds ratio = 3.02; 95% CI = 1.05-8.70).

PERSPECTIVE

The current study provides additional insights into the pain and disability associated with plantar fasciitis, as well as the pharmaceutical treatments being used for its management. Prescription as well as OTC medications are used to manage plantar fasciitis symptoms despite limited, if any, clinical trial data supporting their use.

Diabetes and Cognitive Decline in Older Adults: The Ginkgo Evaluation of Memory Study

BACKGROUND

Previous studies have shown that individuals with diabetes exhibit accelerated cognitive decline. However, methodological limitations have limited the quality of this evidence. Heterogeneity in study design, cognitive test administration, and methods of analysis of cognitive data have made it difficult to synthesize and translate findings to practice. We analyzed longitudinal data from the Ginkgo Evaluation of Memory Study to test our hypothesis that older adults with diabetes have greater test-specific and domain-specific cognitive declines compared to older adults without diabetes.

METHODS

Tests of memory, visuo-spatial construction, language, psychomotor speed, and executive function were administered. Test scores were standardized to z-scores and averaged to yield domain scores. Linear random effects models were used to compare baseline differences and changes over time in test and domain scores among individuals with and without diabetes.

RESULTS

Among the 3,069 adults, aged 72-96 years, 9.3% reported diabetes. Over a median follow-up of 6.1 years, participants with diabetes exhibited greater baseline differences in a test of executive function (trail making test, Part B) and greater declines in a test of language (phonemic verbal fluency). For the composite cognitive domain scores, participants with diabetes exhibited lower baseline executive function and global cognition domain scores, but no significant differences in the rate of decline.

CONCLUSIONS

Identifying cognitive domains most affected by diabetes can lead to targeted risk modification, possibly in the form of lifestyle interventions such as diet and physical activity, which we know to be beneficial for improving vascular risk factors, such as diabetes, and therefore may reduce the risk of executive dysfunction and possible dementia.

Severe Pain in Veterans: The Effect of Age and Sex, and Comparisons With the General Population

This study provides national prevalence estimates of US military veterans with severe pain, and compares veterans with nonveterans of similar age and sex. Data used are from the 2010 to 2014 National Health Interview Survey on 67,696 adults who completed the Adult Functioning and Disability Supplement. Participants with severe pain were identified using a validated pain severity coding system imbedded in the National Health Interview Survey Adult Functioning and Disability Supplement. It was estimated that 65.5% of US military veterans reported pain in the previous 3 months, with 9.1% classified as having severe pain. Compared with veterans, fewer nonveterans reported any pain (56.4%) or severe pain (6.4%). Whereas veterans aged 18 to 39 years had significantly higher prevalence rates for severe pain (7.8%) than did similar-aged nonveterans (3.2%), veterans age 70 years or older were less likely to report severe pain (7.1%) than nonveterans (9.6%). Male veterans (9.0%) were more likely to report severe pain than male nonveterans (4.7%); however, no statistically significant difference was seen between the 2 female groups. The prevalence of severe pain was significantly higher in veterans with back pain (21.6%), jaw pain (37.5%), severe headaches or migraine (26.4%), and neck pain (27.7%) than in nonveterans with these conditions (respectively: 16.7%, 22.9%, 15.9%, and 21.4%). Although veterans (43.6%) were more likely than nonveterans (31.5%) to have joint pain, no difference was seen in the prevalence of severe pain associated with this condition.

PERSPECTIVE

Prevalence of severe pain, defined as that which occurs "most days" or "every day" and bothers the individual "a lot," is strikingly more common in veterans than in members of the general population, particularly in veterans who served during recent conflicts. Additional assistance may be necessary to help veterans cope with their pain.

Use of Complementary Health Approaches for Musculoskeletal Pain Disorders Among Adults: United States, 2012

OBJECTIVE

This report examines the use of complementary health approaches among U.S. adults aged 18 and over who had a musculoskeletal pain disorder. Prevalence of use among this population subgroup is compared with use by persons without a musculoskeletal disorder. Use for any reason, as well as specifically to treat musculoskeletal pain disorders, is examined.

METHODS

Using the 2012 National Health Interview Survey, estimates of the use of complementary health approaches for any reason, as well as use to treat musculoskeletal pain disorders, are presented. Statistical tests were performed to assess the significance of differences between groups of complementary health approaches used among persons with specific musculoskeletal pain disorders. Musculoskeletal pain disorders included lower back pain, sciatica, neck pain, joint pain or related conditions, arthritic conditions, and other musculoskeletal pain disorders not included in any of the previous categories. Respondents could report having more than one disorder.

RESULTS

In 2012, 54.5% of U.S. adults had a musculoskeletal pain disorder. The use of any complementary health approach for any reason among persons with a musculoskeletal pain disorder (41.6%) was significantly higher than use among persons without a musculoskeletal pain disorder (24.1%). Among adults with any musculoskeletal pain disorder, the use of natural products for any reason (24.7%) was significantly higher than the use of mind and body approaches (15.3%), practitioner-based approaches (18.2%), or whole medical system approaches (5.3%). The pattern of use of the above-mentioned groups of complementary health approaches was similar for persons without a musculoskeletal disorder. However, prevalence of use among these persons was significantly lower compared with persons with a musculoskeletal disorder. For treatment, the use of practitioner-based approaches among persons with any musculoskeletal pain disorder (9.7%) was more than three times as high as the use of any other group of approaches (0.7%-3.1%). The patterns of use of specific groups of complementary health approaches also differed among specific musculoskeletal pain disorders.

Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States

Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches-acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga-as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.

Expenditures on Complementary Health Approaches: United States, 2012

OBJECTIVE

This report presents estimates of expenditures on complementary health approach use among the U.S. population. Estimates are presented for adults and children separately and combined, as well as stratified by type of approach and family income.

METHODS

Combined data from 44,743 individuals aged 4 years and over, collected as part of the 2012 National Health Interview Survey, were analyzed for this report. Sample data were weighted to produce national estimates that are representative of the civilian noninstitutionalized U.S. population. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. Linear regression was used to assess trends in expenditures when stratifying by family income.

RESULTS

An estimated 59 million persons aged 4 years and over had at least one expenditure for some type of complementary health approach, resulting in total out-of-pocket expenditures of $30.2 billion. More was spent on visits to complementary practitioners ($14.7 billion) than for purchases of natural product supplements ($12.8 billion) or self-care approaches ($2.7 billion). The mean per user out-of-pocket expenditure for visits to a complementary practitioner ($433) was significantly more than for purchases of natural product supplements ($368) or for self-care approaches ($257). Adults had higher mean annual out-of-pocket expenditures for visits to complementary practitioners than children ($442 and $291, respectively). Total out-of-pocket expenditures and mean per user out-of pocket expenditures for complementary health approaches increased significantly as family income increased. The mean per user out-of-pocket expenditure for complementary health approaches was $435 for persons with family incomes less than $25,000 and $590 for persons with family incomes of $100,000 or more.

Categorizing the severity of pain using questions from the 2012 National Health Interview Survey

Background

Based on qualitative and mixed-method approaches, Miller and Loeb have proposed a coding system that combines questions on pain persistence and bothersomeness to create discrete categories of increasing pain severity for use in large population-based surveys. In the current analyses, using data from the 2012 National Health Interview Survey, we quantitatively assess the pain category definitions proposed by Miller and Loeb and compare this original definition to ten alternative definitions.

Methods

Using multivariate analysis of variance, each definition was related simultaneously to four dependent measures – the Kessler 6 score for measuring psychological distress, the number of health-related bed-disability days, the number of visits to a health professional, and the number of emergency room visits. Following the protocol of Serlin et al, the definition yielding the largest F score was considered the optimal definition.

Results

The Miller and Loeb definition produced the largest F value (185.87), followed consecutively by several alternative definitions #5 (184.17), #10 (180.95), and #9 (179.5). A nearly identical ordering was found when looking at the mean F value generated from 100 random samples. We also examined the frequencies with which each alternative definition achieved the optimal F value over the 100 random samples. Only two definitions had achieved the optimal F value >5% of the time: the Miller and Loeb definition was optimal 46% of the time, while alternative definition #5 was optimal 41% of the time. Similar results were seen in subpopulations with back pain and joint pain.

Conclusion

Additional support was provided for the Miller and Loeb coding of pain persistence and bothersomeness to produce discrete categories of increasing pain severity. This two-question coding scheme may prove to be a viable option for assessing pain severity in clinical settings where clinician time and patient burden are limiting factors.

Insurance Coverage for Complementary Health Approaches Among Adult Users: United States, 2002 and 2012

Data from the 2002 and 2012 National Health Interview Surveys. Between 2002 and 2012, the use of acupuncture, chiropractic, and massage therapy increased among adults who did not have health insurance coverage for these complementary health approaches. No change in use was observed among those who had coverage for these approaches. While 60% of adults who saw a practitioner for chiropractic had at least some health insurance coverage for this approach, far fewer adults seeing a practitioner for acupuncture (25%) or massage therapy (15%) had coverage for these approaches. Adults who saw practitioners for acupuncture and chiropractic-and had health insurance coverage for these approaches-were more likely to have partial than complete coverage.

Wellness-related Use of Common Complementary Health Approaches Among Adults: United States, 2012

OBJECTIVE

This report presents national estimates of selected wellness-related reasons for the use of natural product supplements, yoga, and spinal manipulation among U.S. adults in 2012. Self-reported perceived health outcomes were also examined.

METHODS

Data from 34,252 adults aged 18 and over collected as part of the 2012 National Health Interview Survey were analyzed for this report. In particular, whether adults who used selected complementary health approaches did so to treat a specific health condition or for any of five wellness-related reasons was examined, as well as whether these adults perceived that this use led to any of nine health-related outcomes. Sampling weights were used to produce national estimates that are representative of the civilian noninstitutionalized U.S. adults population.

RESULTS

Users of natural product supplements and yoga were more likely to have reported using the approach for a wellness reason than for treatment of a specific health condition, whereas more spinal manipulation users reported using it for treatment rather than for wellness. The most common wellness-related reason reported by user of each of the three approaches was for "general wellness or disease prevention." The majority of users of all three health approaches reported that they perceived this use improved their overall health and made them feel better. Yoga users perceived higher rates of all of the self-reported wellness-related health outcomes than users of natural product supplements or spinal manipulation.

The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey

BACKGROUND

Most knowledge of fibromyalgia comes from the clinical setting, where healthcare-seeking behavior and selection issues influence study results. The characteristics of fibromyalgia in the general population have not been studied in detail.

METHODS

We developed and tested surrogate study specific criteria for fibromyalgia in rheumatology practices using variables from the US National Health Interview Survey (NHIS) and the modification (for surveys) of the 2010 American College of Rheumatology (ACR) preliminary fibromyalgia criteria. The surrogate criteria were applied to the 2012 NHIS and identified persons who satisfied criteria from symptom data. The NHIS weighted sample of 8446 persons represents 225.7 million US adults.

RESULTS

Fibromyalgia was identified in 1.75% (95% CI 1.42, 2.07), or 3.94 million persons. However, 73% of identified cases self-reported a physician's diagnosis other than fibromyalgia. Identified cases had high levels of self-reported pain, non-pain symptoms, comorbidity, psychological distress, medical costs, Social Security and work disability. Caseness was associated with gender, education, ethnicity, citizenship and unhealthy behaviors. Demographics, behaviors, and comorbidity were predictive of case status. Examination of the surrogate polysymptomatic distress scale (PSD) of the 2010 ACR criteria found fibromyalgia symptoms extending through the full length of the scale.

CONCLUSIONS

Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. The association of fibromyalgia-like symptoms over the full length of the PSD scale with physiological as well as mental stressors suggests PSD may be a universal response variable rather than one restricted to fibromyalgia.

Quality-of-life outcomes with a disodium EDTA chelation regimen for coronary disease: results from the trial to assess chelation therapy randomized trial

BACKGROUND

The National Institutes of Health.funded Trial to Assess Chelation Therapy (TACT) randomized 1708 stablecoronary disease patients aged .50 years who were .6 months post.myocardial infarction (2003.2010) to 40 infusions ofa multicomponent EDTA chelation solution or placebo. Chelation reduced the primary composite end point of mortality,recurrent myocardial infarction, stroke, coronary revascularization, or hospitalization for angina (hazard ratio, 0.82; 95%confidence interval, 0.69.0.99; P=0.035).

METHODS AND RESULTS

In a randomly selected subset of 911 patients, we prospectively collected a battery of quality-of-life(QOL) instruments at baseline and at 6, 12, and 24 months after randomization. The prespecified primary QOL measures were the Duke Activity Status Index (Table I in the Data Supplement) and the Medical Outcomes Study Short-Form 36 Mental Health Inventory-5. All comparisons were by intention to treat. Baseline clinical and QOL variables were well balanced in the 451 patients randomized to chelation and in the 460 patients randomized to placebo. The Duke Activity Status Index improved in both groups during the first 6 months of therapy, but we found no evidence for a treatment-related difference (mean difference [chelation.placebo] during follow-up, 0.9 [95% confidence interval, .0.7 to 2.6; P=0.27]).There was no statistically significant evidence of a treatment-related difference in the Mental Health Inventory-5 during follow-up (mean difference, 1.0; 95% confidence interval, .0.1 to 2.0; P=0.08). None of the secondary QOL measures showed a consistent treatment-related difference.

CONCLUSIONS

In stable, predominantly asymptomatic coronary disease patients with a history of myocardial infarction,EDTA chelation therapy did not have a detectable effect on QOL during 2 years of follow-up.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00044213.

Out-Of-Pocket Expenditures on Complementary Health Approaches Associated With Painful Health Conditions in a Nationally Representative Adult Sample

National surveys suggest that millions of adults in the United States use complementary health approaches such as acupuncture, chiropractic manipulation, and herbal medicines to manage painful conditions such as arthritis, back pain, and fibromyalgia. Yet, national and per person out-of-pocket (OOP) costs attributable to this condition-specific use are unknown. In the 2007 National Health Interview Survey, the use of complementary health approaches, the reasons for this use, and the associated OOP costs were captured in a nationally representative sample of 5,467 adults. Ordinary least square regression models that controlled for comorbid conditions were used to estimate aggregate and per person OOP costs associated with 14 painful health conditions. Individuals using complementary approaches spent a total of $14.9 billion (standard error [SE] = $.9 billion) on these approaches to manage these painful conditions. Total OOP expenditures by those using complementary approaches for their back pain ($8.7 billion, SE = $.8 billion) far outstripped OOP expenditures for any other condition; the majority of these costs ($4.7 billion, SE = $.4 billion) were for visits to complementary providers. Annual condition-specific per person OOP costs varied from a low of $568 (SE = $144) for regular headaches to a high of $895 (SE = $163) for fibromyalgia.

PERSPECTIVE

Adults in the United States spent $14.9 billion on complementary health approaches (eg, acupuncture, chiropractic manipulation, and herbal medicines) to manage painful conditions including back pain ($8.7 billion). This back pain estimate is almost one-third of the total conventional health care expenditure for back pain ($30.4 billion) and two-thirds higher than conventional OOP expenditures ($5.1 billion).

Estimates of pain prevalence and severity in adults: United States, 2012

Using a simple approach for coding pain severity, the present study describes self-reported pain in U.S. adults. Data are included for 8,781 adults who completed the Functioning and Disability Supplement of the 2012 National Health Interview Survey. An internationally piloted pain severity coding system was used to group participants into 5 discrete ordered pain categories based on their pain persistence (days with pain in the last 3 months) and bothersomeness (little, a lot, somewhere in between): pain free and categories 1 (low) to 4 (high). It is estimated that 126.1 million adults reported some pain in the previous 3 months, with 25.3 million adults (11.2%) suffering from daily (chronic) pain and 23.4 million (10.3%) reporting a lot of pain. Based on the persistence and bothersomeness of their pain, 14.4 million adults (6.4%) were classified as having the highest level of pain, category 4, with an additional 25.4 million adults (11.3%) experiencing category 3 pain. Individuals with category 3 or 4 pain were likely to have worse health status, to use more health care, and to suffer from more disability than those with less severe pain. Associations were seen between pain severity and selected demographic variables including race, ethnicity, preferred language, sex, and age.

PERSPECTIVE

U.S. estimates of pain prevalence are presented using a simple approach for assigning pain severity developed by the Washington Group on Disability Statistics. Concurrent validity is assessed. Although this approach is promising, additional work is required to determine the usefulness of the Washington Group pain categories for pain research or clinical practice.

Limited Health Knowledge as a Reason for Non-Use of Four Common Complementary Health Practices

Background

Complementary health practices are an important element of health/healthcare seeking behavior among adults in the United States. Reasons for use include medical need, prevention and wellness promotion, and cultural relevance. Survey studies published over the past several decades have provided important information on the use of complementary health practices, such as acupuncture and yoga. A review of the literature, however, reveals an absence of studies looking specifically at who does not use these approaches, and why not.

Methods

To explore this issue two samples were created using data from the 2007 National Health Interview Survey Complementary and Alternative Medicine supplement. Of particular interest was the relationship between lack of health knowledge, as a reason for non-use, and key independent variables. The first sample was comprised of individuals who had never used any of four common complementary health practices -- acupuncture, chiropractic, natural products, and yoga. The second was a subset of those same non-users who had also reported low back pain, the most frequently cited health concern related to use of complementary therapies.

Results

A hypothesized association between lack of health knowledge, lower educational attainment, and other key socioeconomic indicators was supported in the findings. Although it was hypothesized that low back pain would be associated with greater information seeking, regardless of level of education, that hypothesis was not supported.

Conclusion

Lack of knowledge was found to affect utilization of common complementary health practices, regardless of the potentially motivating presence of back pain. Disparities in the utilization of complementary medicine, related to educational attainment and other socioeconomic factors, may negatively affect quality of care for many Americans. Creative approaches are needed to help reduce inequities in understanding and improve access to care for underserved populations.

Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012

OBJECTIVE

This report presents national estimates of the use of complementary health approaches among children aged 4-17 years in the United States. Selected modalities are compared for 2007 and 2012 to examine changes over time.

METHODS

Data from the 2007 and 2012 National Health Interview Survey (NHIS) were analyzed for this report. The combined sample included 17,321 interviews with knowledgeable adults about children aged 4-17 years. Point estimates and estimates of their variances were calculated using SUDAAN software to account for the complex sampling design of NHIS. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level.

RESULTS

The use of complementary health approaches among children did not change significantly since 2007 (from 12.0% in 2007 to 11.6% in 2012). However, one approach, the use of traditional healers, showed a statistically significant decrease in use, from 1.1% in 2007 to 0.1% in 2012. No other significant decreases were identified. An increase in the use of yoga was observed during this period (from 2.3% in 2007 to 3.1% in 2012). Nonvitamin, nonmineral dietary supplements; chiropractic or osteopathic manipulation; and yoga, tai chi, or qi gong were the most commonly used complementary health approaches in both 2007 and 2012. Also consistent between 2007 and 2012 was that complementary health approaches were most frequently used for back or neck pain, head or chest cold, anxiety or stress, and other musculoskeletal conditions.

Trends in the use of complementary health approaches among adults: United States, 2002-2012

OBJECTIVE

This report presents national estimates of the use of complementary health approaches among adults in the United States across three time points. Trends in the use of selected complementary health approaches are compared for 2002, 2007, and 2012, and differences by selected demographic characteristics are also examined.

METHODS

Combined data from 88,962 adults aged 18 and over collected as part of the 2002, 2007, and 2012 National Health Interview Survey were analyzed for this report. Sample data were weighted to produce national estimates that are representative of the civilian noninstitutionalized U.S. adult population. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level.

RESULTS

Although the use of individual approaches varied across the three time points, nonvitamin, nonmineral dietary supplements remained the most popular complementary health approach used. The use of yoga, tai chi, and qi gong increased linearly across the three time points; among these three approaches, yoga accounted for approximately 80% of the prevalence. The use of any complementary health approach also differed by selected sociodemographic characteristics. The most notable observed differences in use were by age and Hispanic or Latino origin and race.

Infection hospitalization increases risk of dementia in the elderly

OBJECTIVES

Severe infections, often requiring ICU admission, have been associated with persistent cognitive dysfunction. Less severe infections are more common and whether they are associated with an increased risk of dementia is unclear. We determined the association of pneumonia hospitalization with risk of dementia in well-functioning older adults.

DESIGN

Secondary analysis of a randomized multicenter trial to determine the effect of Gingko biloba on incident dementia.

SETTING

Five academic medical centers in the United States.

SUBJECTS

Healthy community volunteers (n = 3,069) with a median follow-up of 6.1 years.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We identified pneumonia hospitalizations using International Classification of Diseases, 9th Edition-Coding Manual codes and validated them in a subset. Less than 3% of pneumonia cases necessitated ICU admission, mechanical ventilation, or vasopressor support. Dementia was adjudicated based on neuropsychological evaluation, neurological examination, and MRI. Two hundred twenty-one participants (7.2%) incurred at least one hospitalization with pneumonia (mean time to pneumonia = 3.5 yr). Of these, dementia was developed in 38 (17%) after pneumonia, with half of these cases occurring 2 years after the pneumonia hospitalization. Hospitalization with pneumonia was associated with increased risk of time to dementia diagnosis (unadjusted hazard ratio = 2.3; CI, 1.6-3.2; p < 0.0001). The association remained significant when adjusted for age, sex, race, study site, education, and baseline mini-mental status examination (hazard ratio = 1.9; CI, 1.4-2.8; p < 0.0001). Results were unchanged when additionally adjusted for smoking, hypertension, diabetes, heart disease, and preinfection functional status. Results were similar using propensity analysis where participants with pneumonia were matched to those without pneumonia based on age, probability of developing pneumonia, and similar trajectories of cognitive and physical function prior to pneumonia (adjusted prevalence rates, 91.7 vs 65 cases per 1,000 person-years; adjusted prevalence rate ratio = 1.6; CI, 1.06-2.7; p = 0.03). Sensitivity analyses showed that the higher risk also occurred among those hospitalized with other infections.

CONCLUSION

Hospitalization with pneumonia is associated with increased risk of dementia.

Regional variation in use of complementary health approaches by U.S. adults

Data from the National Health Interview Survey, 2012 Use of nonvitamin, nonmineral dietary supplements (17.9%) was greater than any other complementary health approach used by U.S. adults in 2012. The use of practitioner-based chiropractic or osteopathic manipulation was nearly twice as high in the West North Central region as in the United States overall. Use of nonvitamin, nonmineral dietary supplements was highest in the Mountain, Pacific, and West North Central regions. Use of yoga with deep breathing or meditation was approximately 40% higher in the Pacific and Mountain regions than in the United States overall. Complementary health approaches are defined as "a group of diverse medical and health care interventions, practices, products, or disciplines that are not generally considered part of conventional medicine". They range from practitioner-based approaches, such as chiropractic manipulation and massage therapy, to predominantly self-care approaches, such as nonvitamin, nonmineral dietary supplements, meditation, and yoga. This report presents estimates of the four most commonly used complementary health approaches among adults aged 18 and over in nine geographic regions, using data from the 2012 National Health Interview Survey adult alternative medicine supplement.

Oral high-dose multivitamins and minerals after myocardial infarction: a randomized trial

BACKGROUND

Whether high-dose multivitamins are effective for secondary prevention of atherosclerotic disease is unknown.

OBJECTIVE

To assess whether oral multivitamins reduce cardiovascular events and are safe.

DESIGN

Double-blind, placebo-controlled, 2 x 2 factorial, multicenter, randomized trial. (ClinicalTrials.gov: NCT00044213) SETTING: 134 U.S. and Canadian academic and clinical sites.

PATIENTS

1708 patients aged 50 years or older who had myocardial infarction (MI) at least 6 weeks earlier and had serum creatinine levels of 176.8 mol/L (2.0 mg/dL) or less.

INTERVENTION

Patients were randomly assigned to an oral, 28-component, high-dose multivitamin and multimineral mixture or placebo.

MEASUREMENTS

The primary end point was time to total death, recurrent MI, stroke, coronary revascularization, or hospitalization for angina.

RESULTS

The median age was 65 years, and 18% of patients were women. The qualifying MI occurred a median of 4.6 years (interquartile range [IQR], 1.6 to 9.2 years) before enrollment. Median follow-up was 55 months (IQR, 26 to 60 months). Patients received vitamins for a median of 31 months (IQR, 13 to 59 months) in the vitamin group and 35 months (IQR, 13 to 60 months) in the placebo group (P = 0.65). Totals of 645 (76%) and 646 (76%) patients in the vitamin and placebo groups, respectively, completed at least 1 year of oral therapy (P = 0.98), and 400 (47%) and 426 (50%) patients, respectively, completed at least 3 years (P = 0.23). Totals of 394 (46%) and 390 (46%) patients in the vitamin and placebo groups, respectively, discontinued the vitamin regimen (P = 0.67), and 17% of patients withdrew from the study. The primary end point occurred in 230 (27%) patients in the vitamin group and 253 (30%) in the placebo group (hazard ratio, 0.89 [95% CI, 0.75 to 1.07]; P = 0.21). No evidence suggested harm from vitamin therapy in any category of adverse events.

LIMITATION

There was considerable nonadherence and withdrawal, limiting the ability to draw firm conclusions (particularly about safety).

CONCLUSION

High-dose oral multivitamins and multiminerals did not statistically significantly reduce cardiovascular events in patients after MI who received standard medications. However, this conclusion is tempered by the nonadherence rate.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Development of the adult and child complementary medicine questionnaires fielded on the National Health Interview Survey

The 2002, 2007, and 2012 complementary medicine questionnaires fielded on the National Health Interview Survey provide the most comprehensive data on complementary medicine available for the United States. They filled the void for large-scale, nationally representative, publicly available datasets on the out-of-pocket costs, prevalence, and reasons for use of complementary medicine in the U.S. Despite their wide use, this is the first article describing the multi-faceted and largely qualitative processes undertaken to develop the surveys. We hope this in-depth description enables policy makers and researchers to better judge the content validity and utility of the questionnaires and their resultant publications.

The effect of an EDTA-based chelation regimen on patients with diabetes mellitus and prior myocardial infarction in the Trial to Assess Chelation Therapy (TACT)

BACKGROUND

The Trial to Assess Chelation Therapy (TACT) showed clinical benefit of an EDTA-based infusion regimen in patients aged ≥50 years with prior myocardial infarction. Diabetes mellitus before enrollment was a prespecified subgroup.

METHODS AND RESULTS

Patients received 40 infusions of EDTA chelation or placebo. A total of 633 (37%) patients had diabetes mellitus (322 EDTA and 311 placebo). EDTA reduced the primary end point (death, reinfarction, stroke, coronary revascularization, or hospitalization for angina; 25% versus 38%; hazard ratio, 0.59; 95% confidence interval [CI], 0.44-0.79; P<0.001) over 5 years. The result remained significant after Bonferroni adjustment for multiple subgroups (99.4% CI, 0.39-0.88; adjusted P=0.002). All-cause mortality was reduced by EDTA chelation (10% versus 16%; hazard ratio, 0.57; 95% CI, 0.36-0.88; P=0.011), as was the secondary end point (cardiovascular death, reinfarction, or stroke; 11% versus 17%; hazard ratio, 0.60; 95% CI, 0.39-0.91; P=0.017). However, after adjusting for multiple subgroups, those results were no longer significant. The number needed to treat to reduce 1 primary end point over 5 years was 6.5 (95% CI, 4.4-12.7). There was no reduction in events in non-diabetes mellitus (n=1075; P=0.877), resulting in a treatment by diabetes mellitus interaction (P=0.004).

CONCLUSIONS

Post-myocardial infarction patients with diabetes mellitus aged ≥50 demonstrated a marked reduction in cardiovascular events with EDTA chelation. These findings support efforts to replicate these findings and define the mechanisms of benefit. However, they do not constitute sufficient evidence to indicate the routine use of chelation therapy for all post-myocardial infarction patients with diabetes mellitus.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00044213.

Prevalence and predictors of children's dietary supplement use: the 2007 National Health Interview Survey

BACKGROUND

Little is known about the characteristics of US children who are dietary supplement users.

OBJECTIVE

We described the prevalence and predictors of and reasons for giving children dietary supplements.

DESIGN

The study included children <18 y of age who participated in the Complementary and Alternative Medicine supplement of the National Health Interview Survey of 2007 whose proxies provided complete information on child dietary supplement use.

RESULTS

A total of 37% of subjects used dietary supplements, 31% of subjects used multivitamin mineral (MVM) products exclusively, 4% of subjects used single vitamins or minerals solely or in combination with MVMs, and 2% of subjects used nonvitamin, nonmineral products either solely or in combination with other supplements. Users were more likely than nonusers to be Asian, white, or non-Hispanic; belong to families with higher parental education and income levels; reside in areas other than the South; be in good, very good, or excellent health; have private health insurance; and have a usual place at which they received conventional medical care. Children (3%) with the most disease burden and health care were more likely to use supplements than were healthier children. Supplements were given for the prevention or treatment of many illnesses and conditions. Neither the caregiver's reasons nor specific supplements used were consistently associated with particular conditions.

CONCLUSIONS

The 37% of US children who used any type of dietary supplements differed from nonusers in family socioeconomic status and many other health-related characteristics. Users were given supplements to prevent or treat many illnesses and conditions for which there is only limited evidence of their efficacy.

Effect of disodium EDTA chelation regimen on cardiovascular events in patients with previous myocardial infarction: the TACT randomized trial

IMPORTANCE

Chelation therapy with disodium EDTA has been used for more than 50 years to treat atherosclerosis without proof of efficacy.

OBJECTIVE

To determine if an EDTA-based chelation regimen reduces cardiovascular events.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, placebo-controlled, 2 × 2 factorial randomized trial enrolling 1708 patients aged 50 years or older who had experienced a myocardial infarction (MI) at least 6 weeks prior and had serum creatinine levels of 2.0 mg/dL or less. Participants were recruited at 134 US and Canadian sites. Enrollment began in September 2003 and follow-up took place until October 2011 (median, 55 months). Two hundred eighty-nine patients (17% of total; n=115 in the EDTA group and n=174 in the placebo group) withdrew consent during the trial.

INTERVENTIONS

Patients were randomized to receive 40 infusions of a 500-mL chelation solution (3 g of disodium EDTA, 7 g of ascorbate, B vitamins, electrolytes, procaine, and heparin) (n=839) vs placebo (n=869) and an oral vitamin-mineral regimen vs an oral placebo. Infusions were administered weekly for 30 weeks, followed by 10 infusions 2 to 8 weeks apart. Fifteen percent discontinued infusions (n=38 [16%] in the chelation group and n=41 [15%] in the placebo group) because of adverse events.

MAIN OUTCOME MEASURES

The prespecified primary end point was a composite of total mortality, recurrent MI, stroke, coronary revascularization, or hospitalization for angina. This report describes the intention-to-treat comparison of EDTA chelation vs placebo. To account for multiple interim analyses, the significance threshold required at the final analysis was P = .036.

RESULTS

Qualifying previous MIs occurred a median of 4.6 years before enrollment. Median age was 65 years, 18% were female, 9% were nonwhite, and 31% were diabetic. The primary end point occurred in 222 (26%) of the chelation group and 261 (30%) of the placebo group (hazard ratio [HR], 0.82 [95% CI, 0.69-0.99]; P = .035). There was no effect on total mortality (chelation: 87 deaths [10%]; placebo, 93 deaths [11%]; HR, 0.93 [95% CI, 0.70-1.25]; P = .64), but the study was not powered for this comparison. The effect of EDTA chelation on the components of the primary end point other than death was of similar magnitude as its overall effect (MI: chelation, 6%; placebo, 8%; HR, 0.77 [95% CI, 0.54-1.11]; stroke: chelation, 1.2%; placebo, 1.5%; HR, 0.77 [95% CI, 0.34-1.76]; coronary revascularization: chelation, 15%; placebo, 18%; HR, 0.81 [95% CI, 0.64-1.02]; hospitalization for angina: chelation, 1.6%; placebo, 2.1%; HR, 0.72 [95% CI, 0.35-1.47]). Sensitivity analyses examining the effect of patient dropout and treatment adherence did not alter the results.

CONCLUSIONS AND RELEVANCE

Among stable patients with a history of MI, use of an intravenous chelation regimen with disodium EDTA, compared with placebo, modestly reduced the risk of adverse cardiovascular outcomes, many of which were revascularization procedures. These results provide evidence to guide further research but are not sufficient to support the routine use of chelation therapy for treatment of patients who have had an MI.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00044213.

Disease severity is associated with the use of complementary medicine to treat or manage type-2 diabetes: data from the 2002 and 2007 National Health Interview Survey

Background

The overall prevalence of complementary medicine (CM) use among adults in the United States with diabetes has been examined both in representative national samples and in more restricted populations. However, none of these earlier studies attempted to identify predictors of CM use to treat diabetes among the populations sampled, nor looked for a relationship between CM use and diabetes severity.

Methods

Combining data from the 2002 and 2007 National Health Interview Survey (NHIS), we constructed a nationally representative sample of 3,978 U.S. adults aged ≥18 years with self-reported diabetes. Both the 2002 and 2007 NHIS contained extensive questions on the use of CM. We used logistic regression to examine the association between diabetes severity and overall CM use, as well as the use of specific categories of CM.

Results

In adults with type-2 diabetes, 30.9% used CM for any reason, but only 3.4% used CM to treat or manage their type-2 diabetes versus 7.1% of those with type-1 diabetes. Among those using CM to treat/manage their type-2 diabetes, 77% used both CM and conventional prescription medicine for their diabetes. The most prevalent types of CM therapies used were diet-based interventions (35.19%, S.E. 5.11) and non-vitamin/non-mineral dietary supplements (33.74%, S.E. 5.07). After controlling for sociodemographic factors, we found that, based on a count of measures of diabetes severity, persons with the most severe diabetes had nearly twice the odds of using CM as those with less severe disease (OR=1.9, 95%CI 1.2-3.01). Persons who had diabetes 10 years or more (OR=1.66, 95%CI 1.04-3.66) and those that had a functional limitation resulting from their diabetes (OR=1.74, 95%CI 1.09-2.8) had greater odds of using CM than those not reporting these measures. No significant associations were observed between overall CM use and other individual measures of diabetes severity: use of diabetic medications, weak or failing kidneys, coronary heart disease, or severe vision problems.

Conclusions

Our results demonstrate that individuals with more severe diabetes are more likely to use CM independent of sociodemographic factors. Further studies are essential to determine if CM therapies actually improve clinical outcomes when used to treat/manage diabetes.

Design of the Trial to Assess Chelation Therapy (TACT)

TACT is an National Institutes of Health-sponsored, randomized, double-blind, placebo-controlled, 2 × 2 factorial clinical trial testing the benefits and risks of 40 infusions of a multicomponent disodium EDTA chelation solution compared with placebo and of an oral, high-dose multivitamin and mineral supplement. TACT has randomized and will follow up 1,708 patients for an average of approximately 4 years. The primary end point is a composite of all-cause mortality, myocardial infarction, stroke, coronary revascularization, and hospitalization for angina. A 900-patient substudy will examine quality-of-life outcomes. The trial is designed to have >85% power to detect a 25% relative reduction in the primary end point for each treatment factor. Enrollment began in September 2003 and was completed in October 2010.

Applying principles from complex systems to studying the efficacy of CAM therapies

In October 2007, a National Center for Complementary and Alternative Medicine (NCCAM)-sponsored workshop, entitled "Applying Principles from Complex Systems to Studying the Efficacy of CAM Therapies," was held at Georgetown University in Washington, DC. Over a 2-day period, the workshop engaged a small group of experts from the fields of complementary and alternative medicine (CAM) research and complexity science to discuss and examine ways in which complexity science can be applied to CAM research. After didactic presentations and small-group discussions, a number of salient themes and ideas emerged. This paper article describes the workshop program and summarizes these emergent ideas, which are divided into five broad categories: (1) introduction to complexity; (2) challenges to CAM research; (3) applications of complexity science to CAM; (4) CAM as a model of complexity applied to medicine; and (5) future directions. This discusses possible benefits and challenges associated with applying complexity science to CAM research. By providing an introductory framework for this collaboration and exchange, it is hoped that this article may stimulate further inquiry into this largely unexplored area of research.

Ginkgo biloba and risk of cancer: secondary analysis of the Ginkgo Evaluation of Memory (GEM) Study

PURPOSE

Evidence from in vitro and in vivo studies suggests that Ginkgo biloba has cancer chemopreventive properties, but epidemiological evidence is sparse. We analyzed cancer as a secondary endpoint in the Ginkgo Evaluation of Memory (GEM) Study, the largest randomized, double-blind, placebo-controlled clinical trial of Ginkgo supplementation to date.

METHODS

A total of 3069 GEM participants 75+ years of age were randomized to twice-daily doses of either 120 mg Ginkgo extract (EGb 761) or placebo and followed for a median 6.1 years. We identified hospitalizations for invasive cancer by reviewing hospital admission and discharge records for all reported hospitalizations over follow-up. Using an intention-to-treat approach, we compared the risk of cancer hospitalization between participants assigned to treatment and those assigned to placebo.

RESULTS

During the intervention, there were 148 cancer hospitalizations in the placebo group and 162 in the EGb 761 group (Hazard ratio (HR), 1.09; 95% confidence interval (CI), 0.87-1.36; p = 0.46). Among the site-specific cancers analyzed, we observed an increased risk of breast (HR, 2.15; 95%CI, 0.97-4.80; p = 0.06) and colorectal (HR, 1.62; 95%CI, 0.92-2.87; p = 0.10) cancer, and a reduced risk of prostate cancer (HR, 0.71; 95%CI, 0.43-1.17; p = 0.18).

CONCLUSIONS

Overall, these results do not support the hypothesis that regular use of Ginkgo biloba reduces the risk of cancer.