By studying [salutogenesis], we can take a different lens in healthcare. Instead of looking at just simply stopping the pathology, we can look at reversing pathology by enhancing our own inherent healing capacity.
In the following interview, Dan Lukaczer, ND, IFM director of medical education, interviews an integrative medicine juggernaut: Wayne Jonas, MD. Dr. Jonas has maintained a successful integrative healthcare practice while helping to change the perception of integrative medicine at the federal level as well as in the US military. Dr. Jonas’s focus on integrative health embraces wellness and salutogenesis, helping clinicians expand their practice to include integrative health approaches, even in practice environments in which such change may be difficult.
Dr. Lukaczer and Dr. Jonas discuss salutogenesis, HOPE and SOAP notes, pain management, and hurdles for incorporating integrative health into primary care. In addition to being the former director of the NIH Office of Alternative Medicine, he also was a former director of the World Health Organization Center for Traditional Medicine and the executive director of the Samueli Integrative Health Programs.
The SOAP note tends to miss a good 80% of what we know leads to health and healing in the encounter. This is lifestyle and behavior.
Intended to be used alongside the standard SOAP note, Dr. Jonas champions the HOPE note, or the Healing-Oriented Practices and Environments note. The HOPE note provides a framework for expanding knowledge and documentation to personalize care for each patient and includes questions about the social and environmental determinants of health, allowing clinicians to track and document the social and behavioral elements of well-being. This expands the scope of a clinical encounter and helps to truly personalize treatment plans and motivate patients for lifestyle change.
Much of Dr. Jonas’s career has been in military settings (he is also a retired Lt. Colonel, United States Army Medical Corps), and he has been instrumental in the adoption of integrative health practices in a variety of military health settings.1-4 Pain is widespread in America, but even higher among individuals who have served in the military.5 The veteran population is more likely to experience pain than other groups (65.5% of veterans, 56.4% of nonveterans), in addition to higher rates of severe pain in veterans aged 18-39 (7.8% of veterans, 3.2% of age-matched nonveterans).6
Non-pharmacologic approaches like yoga have resulted in reduced pain; for instance, yoga decreased pain scores for veterans with lower back pain for as long as six months, even with a concomitant reduction in opioid use.7 In another study, six weeks of cognitive behavioral therapy for veterans also resulted in statistically significant improvements on a range of factors, including pain symptoms, physical function, and satisfaction with care.8 Though some of these studies showed only small reductions in pain scores, a combination of complementary biopsychosocial interventions can lead to much larger overall improvements in quality of life.
As the Federal Pain Research Strategy states, the “complex biological and psychosocial aspects of pain” are important to consider.9 The HOPE note can play a role in helping clinicians understand these aspects, track them, and provide more personalized treatments. Dr. Jonas also highlights the many non-pharmacologic therapies that can reduce pain, providing better quality of life and meeting patient needs.
The opioid epidemic is really just the symptom of a more fundamental underlying problem we have, which is the mismanagement of pain.
- Niemtzow RC, Burns SM, Piazza TR, et al. Integrative medicine in the Department of Defense and the Department of Veterans Affairs: cautious steps forward. J Altern Complement Med. 2016;22(3):171-173. doi:10.1089/acm.2016.29002.rcn
- Smith K, Firth K, Smeeding S, et al. Guidelines for creating, implementing, and evaluating mind-body programs in a military healthcare setting. Explore (NY). 2016;12(1):18-33. doi:10.1016/j.explore.2015.10.002
- Goertz CM, Long CR, Vining RD, et al. Assessment of chiropractic treatment for active duty, U.S. military personnel with low back pain: study protocol for a randomized controlled trial. Trials. 2016;17:70. doi:10.1186/s13063-016-1193-8
- Coulter ID, Hilton L, Walter J, Brown KS. Integrative pain management centers in the military: the challenges. Mil Med. 2016;181(9):1033-1039. doi:10.7205/MILMED-D-15-00317
- Canlas BR, Dawson TC, Hollrah LN, McGranaghan P, Hedt S, Rinehart KJ. Restoring function in veterans with complex chronic pain. Fed Pract. 2017;34(10):42-47.
- Nahin RL. Severe pain in veterans: the effect of age and sex, and comparisons with the general population. J Pain. 2017;18(3):247-254. doi:10.1016/j.jpain.2016.10.021
- Groessl EJ, Liu L, Chang DG, et al. Yoga for military veterans with chronic low back pain: a randomized clinical trial. Am J Prev Med. 2017;53(5):599-608. doi:10.1016/j.amepre.2017.05.019
- Martinson A, Craner J, Clinton-Lont J. Outcomes of a 6-week cognitive-behavioral therapy for chronic pain group for veterans seen in primary care. Transl Behav Med. Published online December 18, 2018. doi:10.1093/tbm/iby127
- The Interagency Pain Research Coordinating Committee. Federal pain research strategy. National Institutes of Health. Updated December 12, 2018. Accessed March 15, 2019. https://iprcc.nih.gov/sites/default/files/FPRS_Research_Recommendations_Final_508C.pdf