By Stephen Smith, Globe Staff | July 5, 2005

http://www.boston.com/news/globe/health_science/articles/2005/07/05/i
nstead_of_pain_pills_try_hard_work/

There is a constant companion in Karen Harrington's life, a visitor
who won't go away.

''It is the pain," said Harrington, 36, whose life has been framed
by an uncommon form of arthritis for a decade and a half.

On some days -- the good days -- her visitor is less insistent. On
others: ''It's absolutely throbbing pain. It wears on you. You have
a bad streak and not only does it get to you physically, it gets to
you emotionally."

She has tried pills and shots and then more pills and more shots.
She never much liked taking all that medication and she always
worried about the harm, along with the good, those drugs might do.

Now her worries, she said, are greater than ever.

A stream of medical studies during the past eight months linked
certain pain relievers with heart complications -- meaning that for
Harrington and other patients facing the ricocheting drumbeat of
pain, the world of pain relief has become an even more dangerous
place.

''Patients are very afraid now of really almost any of the
pharmaceutical agents," said Dr. Elinor Mody, a rheumatologist at
Brigham and Women's Hospital.

And that has spawned a surge of interest in alternatives that don't
involve popping pills. That can mean physical therapy or
acupuncture, visiting a chiropractor or even dipping aching hands in
warm wax.

''When I first started working in this field, I would tell people
I'm going to teach you some meditation and relaxation techniques,
and they would be not interested. They would think it's quackery,"
said Eve Kennedy-Spaien, clinical supervisor for outpatient pain
services at the Spaulding Rehabilitation Network in Medford. ''Now,
people are really interested, and they want to get as much as they
can."

But once a patient embraces an alternative approach, a very
different kind of pain can attack -- in the wallet. Even as such
once-scorned treatments have achieved widespread acceptability in
the high temples of traditional medicine, insurance plans have been
slower to embrace -- and pay for -- those services.

Harrington learned that lesson last week.

When she went to see her rheumatologist, Dr. Robert Shmerling, she
asked about getting his blessing for visits to an acupuncturist so
she could avoid taking more pills. ''I don't want to put all those
chemicals in my body," she said.

Sure, Shmerling responded.

''Absolutely, acupuncture is an option I will offer folks," said
Shmerling, of Beth Israel Deaconess Medical Center.

He even wrote a letter to the insurer stating that, in his opinion,
acupuncture was a medical necessity for treating Harrington's
psoriatic arthritis, which tends to appear in younger adults. Please
cover my patient's acupuncture treatments, Shmerling's letter asked.

He received a quick response: denied.
''It does seem to be different for different insurance companies,"
Shmerling said. ''They're fairly easy to get to cover expensive
medications, but often they won't cover acupuncture or chiropractic
care."

And it's not just patients who worry about whether they will have to
pay out of pocket or not. So do their doctors.

''Every time you're talking to a patient, you're thinking about how
much money do they have, how much can they afford to do this?" said
Dr. Leslie Harrold, a rheumatologist at UMass Memorial Medical
Center. ''Money comes into every conversation, unfortunately."

The state's three biggest health plans all pay for physical therapy,
typically providing two months of treatment a year or per condition.

When it comes to chiropractor visits, both Blue Cross Blue Shield of
Massachusetts and Tufts Health Plan provide some coverage; Harvard
Pilgrim does not, although it has an arrangement with a group of
chiropractors to provide a 25 percent price cut to members who
decide to pay out of pocket.

Acupuncture is not covered by the insurers, but all three plans have
negotiated so that members can get discounts when they pay for
acupuncture themselves.

Decisions on what to cover and what not, the companies said, are
dictated by whether there's sufficient scientific proof validating a
treatment. Tufts Health Plan spokeswoman Catherine Grant explained
that her company favors ''traditional, evidence-based medicine."

But with so many patients suffering so much pain -- an estimated 23
million Americans, for example, have either osteoarthritis or
rheumatoid arthritis -- specialists said they expect the clamor for
alternatives to pills to grow louder.

That's especially true, doctors said, since reports emerged about
serious side effects associated with pain pills. First, last fall,
the maker of the blockbuster pill Vioxx yanked it from the market
after studies showed it heightened the risks for heart attack and
stroke. Later, two other drugs from the same class of medicines,
known as Cox-2 inhibitors, were linked with heart risks.

Then, last month, scientists reported that one of the most widely
used pain relievers, ibuprofen, may slightly increase chances of
being stricken by a heart attack.

Despite that news, some patients remain devoted to their
medication: ''It seems like there are two kinds of people in the
world -- the kind who would absolutely accept something like
acupuncture, and those who would absolutely discard it out of hand,"
Shmerling said. ''The folks who have exhausted the more traditional
therapies are more willing to consider it."

When it comes to acupuncture, doctors now have some solid evidence
showing it really does work. A study published in the Annals of
Internal Medicine in December reported that patients receiving
acupuncture functioned better and had less pain when compared to
patients who received a sham treatment.

Harrington is a believer. When she first tried acupuncture, she paid
$60 a treatment. Now, it's up to $80. And she can't afford that as
regularly as she needs it.

When she found out that her insurer -- which pays for the three
arthritis pills she takes each day, along with the three monthly
injections -- wouldn't pay for acupuncture, she was ''desperate."

''What do I do?" she asked, her voice tinged more with resignation
than anger. ''Take another pill?"

Stephen Smith can be reached at stsmith@....