The number of acupuncturists employed in federally qualified health centers (FQHC) is no longer negligible yet still far from routine. The number who have that experience and have also served their state as members of technology review panels charged to evaluate the science behind non-pharma approaches to pain may be just one. The person doing both in what is essentially a national pilot program in the state of Oregon is Laura Ocker, LAc. I got in touch with Ocker, the past president of the Oregon Association of Acupuncture and Oriental Medicine (OAAOM, for an acupuncture practitioner’s perspective on practicing in the context of the controversial program that led national pain leader Sean Mackey, MD, PhD` to spark a national campaign to limit its expansion. While not fond of the spotlight, Ocker agreed to share some of her experience as part of this ongoing Integrator series.
Ocker was last a subject here as part of a story on bringing the evidence on acupuncture to the Oregon Health Commission to expand coverage, and another on coverage of acupuncture on her state’s pioneering two-pronged move in 2016 on back and neck pain. The Oregon Health Plan required tapering off opioids while at the same time putting new, covered non-pharmacologic treatments in the hands of practitioners and patients. In doing so, the state effectively responded to a letter of 37 state attorney’s generals to cover acupuncture, chiropractic, massage and other such treatment as tools to calm the crisis in chronic pain treatment caused by the US’s exceptional reliance on opioids.
Weeks: You shared with me that some of your passion for this work is that you have personal and familial skin in this game relative to dealing with addiction.
Ocker: If you look at the ACEs scale [Adverse Childhood Events], I’m sure I had a few of those. My step-dad – may he rest in peace – was ex-law-enforcement and a retired, disabled veteran. His physical pain and emotional anguish was very high and he relied on alcohol to self medicate and spoke pretty openly about his alcoholism. The VA sent pain medications into our home by the bucketful. He tried very hard not to take the pain pills, and things never improved when he did. My 20s were pretty rough and tumble. I was engaged in some risky behaviors, including some risky substance use. When I came out to Oregon, I had been living out of a backpack in South America. I had barely a dime to my name. I took odd jobs in construction and landscaping to get by. I was uninsured and without access to (conventional) healthcare this who time and for multiple reasons ended up in what for me was unbearable physical pain while at the same time feeling overwhelmed by ghosts from my past. But I could on occasion scrape together forty bucks to pay for healthcare out of pocket. I started working with a nurse who incorporated Healing Touch and counseling. And a chiropractor who could take the pain away, who over the years became a role model and mentor. My roommates were studying naturopathy, Ayurvedic medicine, and Chinese medicine and taught me how to take better care of myself. Some years later, early into my acupuncture career, I was dismayed to see how many prescriptions were being written for methadone and oxycodone for pain. I had a much different idea about how to work with pain.
Weeks: Thanks for that. It helps explain your passion for your work. The Oregon Health Plan’s strategy has been put in place in the Medicaid population through Federally Qualified Health Centers (FQHC) and other Coordinated Care Organizations. How long have you worked in an FQHC?
Ocker: I’ve worked at 3. I worked as an acupuncturist at Virginia Garcia Memorial Health Center for 5 years then was in private practice for 6 years. I worked on call off and on at Central City Concern for my first 10 years in practice. I’ve now been with Multnomah County – principally at the Northeast Health Center, for 4 years. I’ve worked with Medicaid for the entire 16 years.
Weeks: Has practice changed much since the 2016 Oregon plan to move treatment of back and neck pain by tapering patients off opioids and using more non-pharma care?
Complex practice environment
Ocker: It’s complicated for acupuncture under Medicaid in this period as many different policy things happened at once at multiple levels of government and administration. Some clinics had opioid tapering policies long before the [Oregon Health Authority] implemented the new paradigm for treatment of back and neck pain. It’s really hard to say how things have changed. At our clinic, I have the flexibility to offer acupuncture for any condition appropriate within my scope of practice. But we only get reimbursed by Medicaid if it’s a condition that appears in the funded region of Oregon’s Prioritized List of Health Services. It’s good for our clinic when acupuncture services generate revenue, but we don’t turn patients away. Right now, revenue is generated mainly when I see patients for back and neck pain. I’d like to be able to think more holistically. Sometimes I feel like it would be easy to become reduced to a back and neck pain technician.
Almost all my patients come through provider referrals. A lot of those who actually make it through the door are there because they want to stay away from pharmaceuticals, especially narcotics. Some patients feel that opioids are the only thing that will help but they come in for acupuncture because they need to be able to show good faith that they tried something else. When people think they are being backed into a corner, forced to do something, they often don’t get great results with acupuncture. I do think sometimes when people try acupuncture once or twice and report that it is a negative experience, it’s related not to the acupuncture but to their wanting to get back to what they think they need. Sometimes with those who are on high doses of opioids or chronic opioid therapy there is a kind of fog. It’s hard to reach them with a subtle integrative thinking or practice like acupuncture. They may experience temporary relief with acupuncture, but usually don’t get better without more significant coordinated intervention. We really do see better results when a patient is actively engaged with a taper.
Positive tapering experience
Weeks: Complex environment. How much successful tapering have you seen?
Ocker: It is remarkable also how many positive things can happen. There are a lot of patients who have benefited from a doctor having a hard conversation with them. Patients have said “I can’t believe I was on my back for 3 months” like that on opioids. It’s too bad that the positive stories did not come to light before the chronic pain task force when they listened to testimony. The task force didn’t hear the positive stories. Policies that hurt some people can help others. You don’t always know how the positive will work. Sometimes a patient is hesitant to get counseling, but they’re willing to try acupuncture. They find it relaxes them immensely, and they feel some relief. Little by little, they become more receptive when I suggest counseling, and eventually they may try it.
Weeks: How is it you typically get patients? Are they self-referring? Are they familiar with acupuncture?
Ocker: Most are referred by providers. But they decide to come in or schedule the appointment themselves. Occasionally an appointment is scheduled by the doc’s medical assistant, and I’ll get a patient who has not only never experienced acupuncture but has no clue what it even is, has never heard of it. I see many acupuncture naïve patients. People from Somalia, Ethiopia, South and Central America, and a lot of folks who live right in the neighborhood. Sometimes the people who know little or nothing about acupuncture do very well with even one treatment.
I can’t say what effect exactly acupuncture may be having on opioid use. This is an area where I could have better communication with other providers. I do know that a number of patients have said they need less of other drugs they may be on like ibuprofen or muscle relaxers. Some patients who have not taken opioids for very long also do well with acupuncture and quickly find they don’t need to rely on pain medications. I would say that patients who are on chronic opioid therapy tend to respond differently, sometimes the acupuncture has very little lasting effect. My role is to alleviate pain and suffering. I have to watch myself. I have to be aware of my own judgements coming through. I am a natural practitioner. I have a natural bias.
How useful can non-pharma approaches be?
Weeks: In the dialogue in my last article with the national pain leader Sean Mackey, I shared with him that I thought that the natural health community, the non-pharma provider community, had something of a pumped up view of how if the patients were just given to them, that they could turn this thing around. I told him that I thought I’d had a hand in pumping up some of that feeling. I wonder what you thought reading that.
Ocker: I noticed that. I agree – we as integrative professionals are not going to resolve this on our own. It’s cooperation in multidisciplinary teams that is needed. The crisis is big now and I am not going to come in with my needles and fix it. Idealistically, I like to think that if [typical pain policy and practice] had us there at the front end integrated into the clinic and emergency room settings maybe this [opioid crisis] would never have happened – I can construct a story of what if 15 or 20 years ago people had access to acupuncture, chiropractic and other natural modalities. Would we be where we are now? Maybe not. But it’s so complex. The opioid manufacturers came in and marketed like hell and did some evil work. PCPs learned that opioids were best practice. Patients were struggling with increasing economic pressures and anxieties. Again, idealistically, I am still clinging to the idea if patients have access to acupuncture, chiropractic, behavioral health therapy, physical therapy, and other effective forms of integrative medicine, and systems and providers are committed to no new opioid starts – except in exceptionally rare circumstances or very specific therapeutic situations like end of life cancer care – we can start to turn this ship around. Maybe we can start doing that more now.
Skill-set for preparing to work in this environment
Weeks: You have rare experience, both this much time in the FQHC and with the opioid issue and addiction. As you look back, are there topics that come to mind for a brief primer course that would be good preparation for another acupuncturist or other licensed integrative practitioner before starting in an FQHC, and specifically in working with opioids and addiction?
Ocker: First, I have colleagues I will put you in touch with who have a lot more experience as acupuncturists working with substance use disorders. I’ve thought a lot about this though – what would it help for an acupuncturist to know. Skills in communication with administrators and practitioners. Motivational interviewing. Trauma informed care. Health equity. Basic understanding of substance use disorders. Ability to communicate with [bio-medically trained] practitioners. My biology training helped me in this environment. I know how to speak conservatively and have a research minded tone in the way to present a treatment plan, for instance, or present any outcomes.
Weeks: Funny – for the necessarily entrepreneurial acupuncturist starting a clinic on their own, the tendency is toward marketing with as big of claims as one can make. Very different.
Ocker: Early on [at the FQHC] if someone said they really liked the care and wanted to come in weekly to manage their pain I thought this was a sign of success. Now, while I am sure many of my colleagues would disagree, if I hear that I feel that I am failing them.
Weeks: Fascinating. As chiropractors moved into coverage, they faced the same issue with those who believe a regular “wellness adjustment” was critical. Insurers didn’t agree.
Ocker: Oregon has a great pain education module that’s available to providers. The patients who understand their pain have less pain. So knowing how to communicate about it is important. As I am working with patients giving them their treatment I am continuously engaging in conversation about what turns up the pain signal for them, and how to turn it down.
Weeks: I share your bias that more access to covered acupuncture and other non-pharmacologic methods can certainly provide more tools for turning the pain signal down. Thanks for your work and your frank reflections. This will be a long journey yet to find the best ways out of this mess.