|Managing Chronic Pain: Non-Pharmacological Approaches|
|by Maya A Bass, MD, MA FAAFP, Barbara A Schindler, MD, Dennis Novack, MD|
|© 2016 - 2020 by Drexel University College of Medicine|
Chronic pain is a common disorder seen by physicians. Communication interactions can be challenging for both the clinician and patient. Educating patients on the risks of opiate use and exploring alternate methods for pain management can improve patients’ quality of life.
The CDC defines chronic pain as pain that lasts more than 3 months or longer than would be expected based on the injury. About 20% of adults in the United States have chronic pain (U.S. Census Bureau, Population of Housing Narrative Profile, 2017). Traditionally, chronic pain has been managed by increasing dosage intensity of medication based on the patient’s perception of their pain. This has led to an increase in opioid prescriptions (McCarthy, 2007) Having a prescription for opioids increases the risk for dependence, overdose, and death (Deweerdt, 2019). Recent studies have also found that opioids are not usually effective in treating chronic pain and can lead to significant harm (Afilalo et al., 2010). Other evidence-based modalities have been found to be effective for chronic pain. We will explore those options and how to employ them.
In general, pain is a reaction from activation of the “pain pathway.” Painful stimuli activate the nociceptors in the periphery. This receptor, in turn, sends signals through afferent fibers that have cell bodies in the dorsal root ganglion and interact with neurons in the spinal dorsal horn. These neurons decussate at the ventral commissure and ascend in the lateral spinothalamic tract to the ventral posterolateral nuclei of the thalamus. Signals are then transmitted to the somatosensory cortex and periaqueductal gray matter. This information is also dispersed to the amygdala, hypothalamus, nucleus acumbens, and other regions. There is also a descending pathway that allows for modulation of the pain and it involves the rostral ventral medulla. These connections in the central nervous system integrate the painful stimuli with the areas that manage a person’s executive functioning, memory, and emotional response (Bourne, 2014; Yang 2019).
Most chronic pain disorders produce a similar syndrome of changes in the brain. Both animal and human studies have helped researchers to refine their understanding of these changes. These studies point to the dorsolateral prefrontal cortex (DLPFC) as a consistent target of these changes. This area is attributed with executive functions including planning, working memory, and general cognition. There are also changes noted in all the areas noted in the previous paragraph that are responsible for sensation, memory and the emotional response (Borsook et al, 2012).
Some studies have shown a correlation between chronic pain and decreased grey matter in certain areas of the brain, especially the DLPFC (May, 2011). There is also a change in circuitry causing the inappropriate activation of some parts of the brain, a change in the level of certain neurotransmitters and neuropeptides, and changes in cytokine recruitment and inflammatory markers that are correlated with progression to chronic pain (Yang et al, 2019).
These changes seem to lead to increased activation of the central nervous system without activation of a stimulus in the periphery. The response is also heightened, causing increase activation with minimal stimulus. This can lead to lower pain thresholds and brain activity that is similar to that seen in people with mental health disorders. Likely, the elevated risk for co-morbidities of anxiety and depression in patients with chronic pain is due to these changes in central nervous system activity (Yang et al, 2019)
Through structural, chemical, and behavioral changes, an initial painful stimulus can progress to a chronic disorder. It is difficult to determine if changes in the brain cause the chronic nature of the pain or if they are consequences of it (Yang et al, 2019). Neurobiological mechanisms are also affected by past traumas due to such factors as systemic racism, physical abuse, and sexual abuse. Adverse childhood experiences (ACEs) are associated with pediatric and adult chronic pain. Evidence of cultural differences in pain experience speaks to the profound effect of personal experiences on these processes (Losin et al, 2020). There are also theories that the changes in neurological architecture and functioning may lead to the development of personality and mental health disorders perhaps contributing to the high level of comorbidity between chronic pain, personality disorders, depression, and anxiety (Naylor et al, 2017). More research in the area will hopefully shed more light on the pathophysiology and lead to improvements in treatments.
Over 70,000 people died of a drug overdose in the United States in 2017. Sixty-eight percent of these deaths are attributed to opiates - six times higher than reported in 1999 (Wide-ranging online data for epidemiologic research (WONDER), 2017) Unfortunately, some of these deaths are due to prescription opiates. Common practice is that when patients present with pain, they were typically prescribed acetaminophen or an NSAID. If their pain persists, a stronger pain medication would be prescribed until, eventually, patients would be prescribed an opiate medication. There is also a subset of patients who, after an acute injury or surgery, are given a month’s worth or more of opiates. These methods have led to the high prevalence of opiate prescriptions (McCarthy, 2007) Studies show that if a patient is given an opiate for more than 7 days, whether the pain is acute or chronic, they have a 13% chance of being on that opiate medication in 1 year (Shah et al, 2017). Having an opiate prescription increases your rate of overdose and opiate use disorder (OUD) (Edlund et al, 2014). At this time, over 3 million Americans suffer from OUD (Huecker, 2019). Studies also show that 6.5% of patients will get drugs from a dealer and over 50% will get them from a friend or family member. 4 out of 5 users of heroin, started with a prescription for pain relievers (Huecker, 2019).
Evidence has shown the chronic opiates are not effective treatment for chronic pain (Chou et al, 2015). Patient started on chronic opioids will frequently have worse quality of life when evaluated after years of use (Jensen et al, 2006; Griffen et al, 2015). Thus, physicians should refrain from initiating opioids for chronic pain.
If a patient is already on an opioid the physician must determine if continuing the medication will improve the patient’s quality of life. There are many validated screening tools to help a physician determine if there are signs of misuse such as the Current Opiate Misuse Measure (COMM) (Butler et al, 2010). Using a screening tool in combination with an open and nonjudgmental conversation with a patient about misuse is crucial in determining if there is an underlying use disorder. It is also important to screen patients for co-morbid mental health disorders whose treatment may improve a patient’s perception of pain and quality of life. One example is using the Patient Health Questionaire-2 to screen for depression (Gilbody et al, 2007).
There will be a small subset of patients on chronic opioids that have no signs of misuse. In these patients a risk and benefits discussion should be had. It is imperative that these patients are on a regimen that is less than 90 millimorphine equivalents (MME)/day (see chart below). Once that is established, maintaining patients on their dose is an option. These patients should still be offered adjunct treatments to help improve their functionality. Visits should continue to include screening for signs of misuse and co-morbid conditions as well as a risk benefit discussion about continuing the medication.
If a patient shows signs or misuse or is on high dose regimen of opioids, a taper should be initiated. The CDC recognizes that tapering opiates can be challenging for both patient and provider. The first goal is to get all patients below 90 MME/day. This number is calculated by converting whatever opiate a patient is taking to Morphine and then calculating how much a patient takes each day.
|Drug name (mg unless otherwise specified)||Conversion Factor|
Statistically, patients on >90MME are at a higher risk for overdose so it is critical to get patients below that threshold. At less than 50MME/day the risk for overdose changes dramatically. In addition to getting patients to a safer dose of opiates, providers should prescribe naloxone nasal spray to all patient taking opioids (Dowell et al, 2016).
Open communication with the patient is vital to ensure therapeutic success. If a patient is willing to taper completely off or, if a patient is showing signs of opiate use disorder (OUD) (see other module for how to diagnose), the tapering should be done slowly. Based on CDC recommendations, if a patient has been on opiates for less than 1 year, they can be tapered by 10% a week. If a patient has been taking the medication for more than a year the goal should be 10% a month. It is important to create a trusting relationship with the patient. Also, tapering may not be a linear line. Holding to a dose to allow patients to manage withdrawal symptoms is okay. Be cautious not to increase the dose. If at any point during the taper a patient shows signs of OUD, they should be transitioned to a medication assisted treatment options (see other module) (Dowell et al, 2016).
During a taper it is crucial to make sure patients feel supported. Screening for mental health conditions and abuse history is crucial for understanding the experiences that may be worsening a patient’s perception of pain. In most instances, patients will benefit from counseling for any comorbid conditions. Initiation of a serotonin uptake inhibitor or other agent for management of depression or anxiety may also be helpful. If a physician does not feel comfortable managing mental health disorders, they should refer patients to a psychiatrist.
Many patients undergoing a taper will experience withdrawal symptoms. Physicians can prescribe symptomatic treatment for these patients. Common medications used are alpha agonists for agitation, antiemetics for nausea, antidiarrheals for diarrhea, and sleep aides for insomnia. It is important to stay away from addictive substances so medications like trazodone or melatonin are preferred over other hypnotics. Many patients will also experience increases in perceived pain. Physicians can reassure patients that increases are temporary and can also offer patients non-pharmacological approaches to pain management. These methods can be used as prevention from starting a patient on an opioid medication, as replacement during an opioid taper, or as adjunct for when a patient needs more pain relief but is already on an opioid.
It is considered best practice to based treatment plans on evidence-based recommendations. The research on pain is not entirely decisive. Most of the following recommendations are based on Low to Moderate level evidence. Studies are small and some have considerable bias making it hard to make these options “Standard of Care.” However, one can compare these with the medication and interventional options available to make an educated decision on what may improve a patient’s quality of life.
There are many interventions available including injections, implantation of stimulator devices, and surgery. This module will not focus on these as many require the use of cortisone. Typically, these are administered by a pain specialist. The evidence is good for pain and function in acute pain but low to insignificant changes are seen in chronic pain (Chou et al, 2017).
Chronic pain is improved with physical modalities. The main types that have shown some improvements are exercise, physical therapy (PT), and yoga.
Exercise can range from home exercises to participation in personalized regimens supervised by a trained individual. The evidence for pain and function, favors the later. Home exercises do not significantly affect chronic pain if done without any other modality. Guided exercises do have small improvement in chronic pain and function based on Moderate level evidence (Chou et al, 2017).
Physical therapy is considered standard of care for back pain It also has a role in care of chronic pain. There was moderate level data showing small improvement in both pain and moderate improvement in function. These were lasting changes based on assessment at 1 year (Filiz, 2019; Chou et al., 2017).
Yoga is also effective in the management of chronic pain. It has reasonable level of evidence for moderate improvement in both pain and function. However, if the patient stops using yoga, the long-term effects were not statistically significant (Chou et al, 2017).
All of these modalities encourage patient to move their bodies. Yoga adds a mindfulness component as it requires patients to be grounded in their breath and body during the practice. These modalities also help to decrease the risk of falls which can create a huge setback for someone already suffering from chronic pain. Employing these modalities encourages patient to combat the deconditioning that happens when patients suffering from chronic pain are afraid to hurt themselves and restricts their movement.
Mental Health Modalities
Chronic pain, unlike acute pain, is affected heavily by emotions and patient thinking/cognition. This is based on studies looking at brain activity. Given this, pain treatment should include a component focused on a patient’s mental health. Studies have highlighted 3 specific modalities—Acceptance Commitment Therapy (ACT), Cognitive Behavior (CBT) Therapy, and Mindfulness Based Practices, as modalities that improve both pain and function. They have also been shown to have lasting effects up to 12 months. All of these methods have an addition positive impact as they also treat depression and anxiety, common co-morbidities of pain. As a practitioner, you can learn to use these modalities with patients. More frequently, however, you can find mental health counselors in your community who will work with your chronic pain patients using these techniques.
ACT has moderate level evidence for reasonable improvement of pain and function even after 12 months (Hughs et al, 2017; Chou et al, 2017). ACT is based on the theory of accepting the hard parts of life and focusing on doing things that give a person purpose and quality of life. One way to understand the basis of this technique is the story of the “unwanted guest”. Imagine you are hosting a party. All of your friends are there, and you are having a great time. Then, your neighbor, whom you don’t like and didn’t invite, shows up. You ask him to leave, but later notice he has lingered. You see him annoying a friend and escort him out of the house. Later, while enjoying a conversation, the unwanted guest sneaks back in. You angrily escort him out and decide to stand by the door so you can make sure he doesn’t come back into the house. The party ends with you still waiting by the door. Unfortunately, you had missed the rest of the party. If instead, you just let the unwanted guest in and went back to enjoying your party, you wouldn’t have missed anything. Sure, he may annoy a guest or two but overall, you wouldn’t have missed out. The party may not be perfect, but parties rarely are.
Pain can be the same thing. If the focus is on keeping the pain at bay, then the patient misses out on life. Instead, encourage the patient to focus on enjoying experiences and improving their quality of life. ACT also encourages patient to re-connect with their purpose to allow them to rely on that in times of struggle. Instead of focusing on pain, the patient can focus on their purpose.
CBT has moderate level evidence for fair improvement of pain and function even 12 months later (Knoerl et al, 2016). In head to head studies, ACT was statistically superior, but it was a very small difference and may not be clinically relevant (Chou et al, 2017). CBT focuses on the interplay between once’s thoughts, emotions, actions and behaviors. A thought can cause an emotion which causes an action. When that action is repeated, it becomes a habitual behavior. Now, that action can happen even without the initial emotion. CBT teaches patients to identify the initial thought and test it or change it before it activates the pathway. For example, you could ask a patient, “what is your first thought when you wake up and notice that it is 3am?” Some people, typically ones without sleep issues, will say “Oh I can sleep more, so I turn over and go back to sleep.” Others, who have issues with insomnia, will say “Oh no, now I am up. Then I will struggle to fall back to sleep.” Thoughts are powerful. CBT teaches patients to looks at thoughts and test them with facts or pause before they evoke an emotion and action. These coping mechanisms will translate into helping patients with pain. This will also help to stop them from catastrophizing symptoms.
Mindfulness is another psychological tool for pain that has a moderate level of evidence for a small impact on pain and function. The best studies have been focusing on Mindfulness-Based Stress reductions. This is an 8-week course created by Jon Kabat Zinn. Each session is 2-3 hours long and participants are encouraged to do a daily meditation practice. The sessions focus on educating participants in bring a non-judgmental focus on the present moment. It educates participants on breathing, meditation, and mindful movement practices (Chou et al, 2017).
These modalities help improve patient’s perception of their pain and help them to focus on improving their quality of life. It also helps them to combat the social isolation that occurs when a person with chronic pain starts to withdrawal from society due to fears of falling, getting hurt, being judged, or ruining an event.
Integrative medicine modalities are finally beginning to be evaluated in research. We will focus on the best studied modalities—acupuncture, acupressure, manipulation, and massage.
Acupuncture is the strategic placement of needles in points of the body to adjust the flow of Qi to improve different body functions. When compare with placebo, Acupuncture has moderate level evidence for moderate improvement in pain. There are less studies on function, but that evidence is moderate level for moderate improvement. The results do not last more than 6 months unless the patient continues to receive treatments. When compared to sham acupuncture, where needles or none penetrating needles are placed throughout the body at random points, there is low quality evidence and the difference is smaller. This may mean that there is a therapeutic aspect of the visits themselves that happens whether the needles are placed correctly or not. The issue with acupuncture is that it is only now getting coverage from certain insurance plans. Thus, many patients are forced to pay for the service out of pocket. This can be a huge financial burden when many treatments require weekly visits. Some clinics have moved to a sliding scale to allow for more accessibility. Auricular acupuncture, which focuses on points only in the ears has allowed acupunctures to do group visits or even offer services in waiting rooms. There are also grants allowing some auricular acupuncturists to offer waiting room treatments to patients for free (Chou et al, 2017).
Manipulation includes both chiropractor adjustments as well as Osteopathic Manipulative Treatment. These have Low to moderate level evidence for a small effect on pain and function. This response was improved when the adjustment was done in conjunction with a prescribed exercise regimen. Some insurance companies will pay for these while other will not. Effects are very dependent on provider experience and expertise (Chou et al, 2017).
Massage varies depending on the type. It can be light touch to deep pressure and kneading. It varies by practitioner and style. It has low level evidence for no improvement in chronic pain. It does have a better effect for acute pain. Not only does it vary in effect, but it varies greatly in price and can be prohibitive to many patients with limited resources (Chou et al, 2017).
Overall, the best effect is a combination of the above modalities. Studies have shown that combining physical and psychological modalities yields the most improvement in pain and function compared to one modality alone or control. Also, these changes have last long-term with studies assessing them up to 12 months out (Gatchel et al, 2014; Chou et al, 2017).
We live in a society that desire a quick fix. That desire is also apparent in our patients with chronic pain. Many will want a pill that “makes it go away.” However, there is no perfect pill. These techniques can help patients create healthy coping mechanisms for managing their pain. Instead of immediately reaching for a “pain pill” they can use one of the aforementioned tools so that they can get some quality of life back. Patients may be hesitant at first, but armed with evidence-backed methodology, you can encourage them to try sometime new and improve their quality of life.
Now that we have established an understanding of chronic pain and options for management, let’s apply it to a patient case. Watch the following case and ask yourself:
- What is your reaction when you have a chronic pain patient on your schedule?
- How are the neurobiological changes of chronic pain expressed by the patient?
- What risks does this patient face by continuing to take opioid medications?
- What techniques are applied to management of the patient?
- What techniques would likely be successful with this patient?
- What things were done well by Dr. Bass?
- What areas could have improved the visit?
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Maya A. Bass, MD, MA FAAFP
Drexel University College of Medicine
Barbara A. Schindler, MD, DFAPA
Drexel University College of Medicine
Dennis H. Novack, MD
Drexel University College of Medicine
|Video Camera, Light
George Zeiset B.A.