Monday, May 21, 2018

An Open Letter to the National Center for Complementary and Integrative Health

By Christine Goertz, DC, PhD 

On May 9, I had the honor of participating in a workshop at the 2018 International Congress on Integrative Medicine and Health in Baltimore with former and current senior staff at the National Center for Complementary and Integrative Health (NCCIH)--formerly the National Center for Complementary and Alternative Medicine (NCCAM)--at the National Institutes of Health (NIH).  

The name of the workshop was “Looking Back, Looking Forward: NCCIH at 20”. From the perspective of one of the very first NCCIH program officers nearly 20 years ago, I spoke about how the Center’s vision, strategic thinking and targeted projects had evolved since those early years.1 I was followed by Margaret Chesney, PhD,2 who joined NCCIH as deputy director in 2003. Dr. Chesney spoke about important efforts during her time there, including development of the NCCIH 2006–2011 Strategic Plan.3 This look back was followed by presentations delivered by Emmeline Edwards, PhD,4 (current director of the Division of Extramural Research) and Acting NCCIH Director David Shurtleff, PhD,5 on NCCIH’s current work and future priorities.6 

Preparing to give this talk provided an opportunity for me to reflect on my deep history with NCCIH. While working as a program officer from 2000-2003 and as the sole state-licensed CIH practitioner, I managed a broad multimillion dollar research portfolio that spanned the breadth from manual therapies to acupuncture, pain to cardiovascular disease, basic science to health services research. I remain as committed to the Center as I was when I joined the staff in 2000 because I believe strongly in the very important and unique leadership role that the it has and must continue to play in determining the appropriate role for complementary and integrative health care (CIH) approaches within the United States healthcare delivery system and because I believe that such work has never been more critical.  

Although the United States spends more on health care per capita than any other country in the world, we lag far behind many nations in key health indicators,and our healthcare system is overwhelmed by those suffering from multiple co-morbid conditions and hard-to-treat symptoms such as pain, depression and anxiety.8 We desperately need a healthcare delivery system 1) that is able to consistently provide evidence-based, patient-centered care to the right individual at the right time, 2) for which the patient care trajectory for chronic conditions begins with the safest, most conservative, effective option available and, 3) that empowers patients and providers with the knowledge and tools they need to make informed decisions that are deeply rooted in disease prevention and health promotion. Much work lies ahead in identifying how CIH practices can best contribute to this effort. Fortunately, a great deal of groundwork has already been established by NCCIH and others, and thoughtful, well-conceived roadmaps exist to guide the way. Examples include the NCCIH 2016 Strategic Plan and the Federal Pain Research Strategy9 released by the Interagency Pain Research Coordinating Committee. As part of these strategies, below are several suggestions that I believe will further those efforts. 

Focus on Priority Conditions  

Given the broad mission and scarcity of available resources, it is critical that NCCIH continue to maintain a sharp focus and leverage strategic partnerships while keeping the door open to support outstanding investigator-initiated research. The Center’s current scientific priorities--nonpharmacologic management of pain, neurobiological effects and mechanisms, and disease prevention and health promotion--are all deserving of rigorous scientific study given gaps in knowledge and the potential for further investigation to have a direct, positive impact on human health.  

Basic Science on Pain 

NCCIH is right to focus both intra- and extramural programs on the biological effects of commonly used and potentially efficacious CIH approaches for pain. Filling such gaps can impact CIH care delivery in two important ways. Basic science is necessary to inform future clinical and translational research efforts in determining which patient populations are most likely to benefit and how therapies can be streamlined and improved. Further, establishing biological plausibility addresses the concerns of skeptics, potentially leading to greater use and integration of effective CIH approaches. In addition to NCCIH’s individual efforts in this area, opportunities to partner with the NIH Neuroscience Blueprint, the BRAIN project, the All of Us Research Program, and the Federal Pain Research Strategy should continue to be explored.  

Clinical Research on Pain 

The rigorous clinical evaluation of CIH practices for pain should also remain a priority. From its inception, NCCIH has collaborated with other federal agencies and important work is ongoing to evaluate the use of CIH as part of a national nondrug therapy strategy to combat opioid use through initiatives such as the NIH-DoD-VA Pain Management Collaboratory and the Interagency Pain Research Coordinating Committee. However, more can be done. Within the past year, organizations such as the American College of Physicians (ACP) and The Joint Commission have recommended nonpharmacological therapies, including many that fall within the purview of NCCIH, as first-line interventions for patients suffering from musculoskeletal pain. NCCIH has an opportunity to build on NIH public-private partnership models and stakeholder-driven models initiated by the Patient Centered Outcomes Research Institute (PCORI) to form new innovative partnerships for the study of CIH that bring together scientists, patient advocacy groups, organizations such as ACP and The Joint Commission and CIH academic/professional associations. Together, these groups could work to identify gaps between the recommendations referenced above and clinical practice, identify barriers and facilitators to address those gaps, build a common research agenda around gaps in evidence regarding treatment effects/safety and health systems implementation that puts the best interests of the patient first, and then develop a public-private funding plan that includes contributions from committed stakeholder groups.  

Examples of Additional Focus Areas 

If successful, the multi-stakeholder model described above could subsequently be used by NCCIH and others to better identify how CIH can contribute to other priority areas. This includes disease prevention and health promotion as well as addressing the overuse of antibiotics. Continued exploration is needed to learn more about the potential link between overuse of antibiotics and obesity and to better determine the role, if any, that pre- and probiotics have in addressing this issue.10 In addition, the clinical effectiveness and mechanisms of CIH therapies for conditions where antibiotics are commonly used but not shown to be effective could be explored.11 

Improving the Science  

NCCIH should continue to place an increasing emphasis on pragmatic study designs as part of its commitment towards the study of CIH in “real world” settings. However, important work must be done to improve the rigor of pragmatic study methods and ensure that pragmatic clinical protocols funded by NCCIH can be reproduced in future studies and translated into clinical practice. This includes the development and testing of clinical care pathways, harmonization of outcome measures across studies, and ensuring that sample sizes are large enough to conduct important subgroup analyses. Existing partners in this effort include the NIH Health Care Systems Research Collaboratory and the NIH/DoD/VHA Pain Collaboratory. Potential additional partners include both the PCORI Methodology Committee and PCORnet.12  

Enhancing Dissemination  

NCCIH is already proactive in the dissemination and implementation of research findings through its excellent website, media strategy, expanding Twitter outreach and requirements that all funded applications include a dissemination/implementation plan. Efforts to bring additional stakeholders such as professional associations, patient advocacy groups and policy-makers into the research process, as described above, can be used to advance successful dissemination strategies by creating broad, early investment in targeted initiatives. The American Chiropractic Association also proposes that NCCIH look at its early initiatives to disseminate CIH information in medical schools and evidence-based clinical practice tools in CIH academic institutions. These initial efforts provide a roadmap for taking an innovative approach in creating initiatives with similar goals and could 1) expand knowledge of CIH in medical schools, providing new tools to primary care physicians and others as we grapple with how to address the opioid crisis, and 2) expand knowledge regarding evidence-based clinical practice in CIH academic institutions, assisting CIH clinicians in better facilitating the integration of evidence-based CIH practices within multi-disciplinary healthcare delivery settings, including the Patient Centered Medical Home and Accountable Care Organizations.  

Training the Next Generation of CIH Scientists 

Training the next generation of CIH researchers becomes increasingly critical as young scientists continue to face stiff competition for NIH funding. In additional to long-standing efforts to build a CIH research workforce among conventional scientists, NCCIH could explore additional ways in which to encourage CIH clinicians to seek research training. For instance, efforts to expand EBCP training in CIH academic institutions could lead to increased interest on the part of these clinicians to consider a career in science. This effort could be supported by leveraging the public-private partnerships described above to add “slots” to T32 training initiatives at research-intensive universities that are specifically targeted towards trainees with a CIH clinical background. These opportunities would be similar to those supported by NIH in terms of qualifications and training but the majority of the funding would come from CIH academic institutions and professional associations. NCCIH could also develop ways to support training for “clinician scientists,” those who make important contributions to research efforts but are unlikely to become independently funded investigators.   

Dr. Goertz is senior scientific advisor for the American Chiropractic Association. She is also CEO of the Spine Institute for Quality (Spine IQ). 

References

  1. https://nccih.nih.gov/sites/nccam.nih.gov/files/about/plans/fiveyear/fiveyear.pdf 
  2. https://www.osher.ucsf.edu/research/research-team/core-faculty/2511-2/ 
  3. https://nccih.nih.gov/sites/nccam.nih.gov/files/about/plans/2005/strategicplan.pdf 
  4. https://nccih.nih.gov/about/staff/edwards.htm 
  5. https://nccih.nih.gov/about/staff/shurtleff 
  6. https://nccih.nih.gov/sites/nccam.nih.gov/files/NCCIH_2016_Strategic_Plan.pdf 
  7. http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective (Accessed 2/20/2018) 
  8. http://vizhub.healthdata.org/gbd-compare (Accessed 2/26/2018) 
  9. https://iprcc.nih.gov/sites/default/files/iprcc/FPRS_Research_Recommendations_Final_508C.pdf 
  10. Jess T. Microbiota, antibiotics, and obesity. N Engl J Med. 2014 Dec 25;371(26):2526-8. doi: 10.1056/NEJMcibr1409799. 
  11. Ventola CL. The Antibiotic Resistance Crisis: Part 1: Causes and Threats. Pharmacy and Therapeutics. 2015;40(4):277-283. 
  12. https://www.pcori.org/research-results/pcornet-national-patient-centered-clinical-research-network (Accessed 2/28/2018) 

 

 

 

 

 

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