Dr. Axelsson and Jesse explain how to treat chronic pain without opioids. Written by Anika Soleyn, MS4, Ross University School of Medicine. Edited by Jesse Lamb, MS3, American University of the Caribbean; Hector Arreaza, MD; and Fiona Axelsson, MD.
Dr. Axelsson and Jesse explain how to treat chronic pain without opioids.
Written by Anika Soleyn, MS4, Ross University School of Medicine. Edited by Jesse Lamb, MS3, American University of the Caribbean; Hector Arreaza, MD; and Fiona Axelsson, MD.
This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.
Axelsson:Welcome to the first episode of 2023, Happy new year! Today is January 10, 2023.
What is chronic pain?
According to the International Association for the Study of Pain, chronic pain is nonstop or reoccurring pain that lasts more than 3 months or beyond the expected clinical course of illness. Chronic pain can adversely affect well-being and quality of life. We used to think of pain as a response to tissue damage, and as the tissue heals, the pain dissipates, but chronic pain is much more complex than that because there may be no evidence of tissue damage, yet the nociceptors keep sending signals to the brain that there is damage.
There are 3 options for the management of chronic pain: non-pharmacologic, nonopioid pharmacological and opioid management.
CDC recommends a combination of nonpharmacological and non-opioid management for chronic pain. The 7 most common chronic pain conditions are neuropathic pain, fibromyalgia or chronic pain syndrome, osteoarthritis, inflammatory arthritis, low back pain, chronic headache, and sickle cell anemia.
Opioids in long-term care facilities.
The use of opioids for the treatment of pain is common in the post-acute and long-term care setting. From the AFP Journal, the Choosing Wisely Recommendation states: “Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.”
The Society for Post-Acute and Long-Term Care Medicine published a statement in 2018 about the use of opioids. It states that the prescription of opioids should be based on an interprofessional assessment specifying why opioids are needed. When long-term opioids are not being used for cancer, palliative care, or end-of-life care in a long-term facility, a tapering plan must be “individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with non-pharmacologic therapies and non-opioid medications”.
Long-term opioid prescriptions should be reviewed regularly and take into consideration the potential harms of opioids. Clinicians are encouraged to offer alternatives such as behavioral therapy, non-opioid analgesics, and other non-pharmacologic treatments whenever available and appropriate.
Initial assessment: Identify biopsychosocial factors and identify if the source is neuropathic, nociceptive, or central sensitization. This can be a challenging process and it may require several visits to determine the origin of pain. Neuropathic pain is due to nerve damage or irritation while nociceptive pain is due to tissue damage. Central sensitization is an abnormal response of the nociceptive system. There are changes in the nervous system that alter how it responds to sensory input that causes widespread pain with no apparent cause or in response to mild sensory input. Some examples include fibromyalgia, migraines in response to brushing hair, surgical scar pain, etc.
Set goals and expectations: It is crucial to set up patient expectations if they have chronic pain. They should understand that pain can be improved to a manageable level but not always eliminated. Patients should have routine follow-up visits with education, and reassurance since they are shown to improve outcomes of pain management. Specific goals such as improved mobility and ability to do certain enjoyable tasks are more reasonable and specific goals than a goal of pain elimination. A good physician-patient relationship and clear communication are essential here. Patients could obviously become deeply upset at the prospect of pain that can’t be eliminated, and those who have received opioids for their pain in the past could be even more distraught at the thought of not getting them now or needing to reduce their dose. The physician should be ready to have this discussion with their patients that have chronic pain and be ready to address their concerns appropriately.
Reduce catastrophic thinking: Pain is an alarm system letting someone know there is some sort of damage. Because of this, it makes sense that a patient would respond to pain with anxious and catastrophic thinking. Patients who understand their own chronic diseases are more likely to be actively involved in their treatment, so understanding is crucial in the management of pain. Reducing fearful thoughts such as "there must be something wrong," and "hurt means harm’” is an important first step toward pain self-management and making sure the strategies attempted are effective.
Rehabilitation: Focused pain clinics often include educational group classes for patients in distress. The programs include explanations for why pain might be present with no pathological factors. It also includes relaxation and mindfulness that help patients soothe themselves during attacks.
The brain plays a big role in the experience of pain. Changing how your brain relates physical pain to stress and reducing those psychosocial barriers through self-care helps with pain management. Finding things that make you physically stronger like physical therapy or occupational therapy help, but also increasing mental strength by doing things that make you happy and having a quality social life is a strong determinant of how the brain perceives physical pain. Consistency is key in pain management even after the patient begins to feel better.
Non-pharmacologic therapy – Most of what we will talk about today is non-pharmacological treatment. We will discuss the options and goals of different treatments. Chronic pain treatment should start with non-pharmacological approaches and then you can add medications if necessary. Again, these approaches aim to increase functionand reduce progression despite chronic pain.
There should be a consistent non-pharmacological regimen, even if medications are added later. The three main approaches will be physical therapy, psychological therapy, and some integrative medicine methods.
Physical therapy. The objective of physical therapy is to improve physical function. You should recommend programs that are specific for patients’ limitations and the physical therapist should have trained specifically in chronic pain treatment. This ensures they do a proper initial evaluation and select appropriate therapeutic methods such as
Therapeutic exercise: Sometimes patients can become so fearful of painful movement that they have deconditioned muscles. In the geriatric population, some patients are so afraid of falling, that they avoid any form of movement whatsoever, therefore almost certainly leading to falls due to deconditioning of those muscles. Adding small amounts of exercise as tolerated can begin to recondition patients and help them build strength. Patients with severe osteoarthritis are more likely to tolerate aquatic exercises.
Therapeutic exercise programs may be available at the physical therapy facility or community centers. Patients can even find videos on the internet of tai chi, yoga classes, Pilates, and low-impact fitness programs. Exercise can certainly reduce pain and improve function, with few adverse effects but make sure patients tolerate the exercises and are not pushed beyond their limits. Stretching can also improve range of motion and strength, especially in chronic lower back pain patients.
Psychological therapy:
Cognitive-behavioral therapy. It is the most researched and recommended psychological treatment for chronic pain. It’s normally recommended in conjunction with patient education, physical therapy, and exercise. CBT can be used after introducing meds and/or after surgery. There are 2 components to cognitive behavioral therapy: cognitions and behaviors. CBT addresses the way that patients’ thoughts (cognitions) affect their actions and vice versa. This begins with helping patients identify situations and environments that trigger their pain and what they actually experience emotionally, behaviorally, and physically when they have pain.
CBT addresses mental responses that may worsen pain, so patients learn to think about how they view their pain. To do this, they use a range of specific behavioral strategies such as relaxation and controlled-breathing exercises, activity pacing, pleasurable activities, improving their sleep, and cognitive reappraisal strategies, such as reframing negative situations to positive or practicing gratefulness.
Complementary and integrative health therapies.
-Mindfulness-based stress reduction. Mindfulness is the ability to be fully present where we are and what we’re doing, and not be overly reactive or overwhelmed by what’s going on around us.
-Progressive muscle relaxation. For instance, tensing/relaxing muscles throughout the body along with positive imagery and meditation.
-Biofeedback. During biofeedback, you’re looking at biological signs, and feedback that is being correlated to physical sensations in your body to recognize the correlation between physical signs and symptoms of chronic pain. You’re connected to monitors, such as electromyograms or electroencephalograms, to quantify muscle tension, brain waves, heart rate, and blood pressure to see how fluctuations and abnormal numbers physically feel in the body.
-Massage therapy.
It can relax painful muscles, tendons, and joints and relieve stress. The effect of pressure in certain areas that are tender causes relaxation and secretion of endorphins that can calm pains. That’s why massage therapy can actually be addictive for some people, because of the endorphins. Another benefit of massage therapy is that it can help with improved absorption of medications due to improved circulation.
There are many other integrative health therapies including Reiki, hypnosis, therapeutic touch, healing touch, and homeopathy. However, these are not well-researched and can’t really be endorsed by evidence-based medicine.If patients are interested in trying complementary, integrative health therapy, you can guide them to practices that are at least safe.
Some therapies can end up being harmful, such as herbal remedies or supplements with potential toxicities or known interactions with medications, so those should be taken cautiously. Make sure your med list while taking your history includes supplements and herbs patients might be trying.
Shirodhara is an Ayurvedic approach to stress relief that involves having someone pour liquid — usually oil, milk, buttermilk, or water — onto your forehead.
Herbal or plant-based treatments have also shown some efficacy in published studies. Ginger, turmeric, St John’s Wort, and a handful of others seem like they could have some beneficial effects either on their own merit or as an adjunctive with other non-opioid therapies. Caution should be taken, though, as some of them, particularly St John’s Wort, have been shown to have negative impacts on serum levels of opioids when used in combination with them due to their effects on the liver cytochrome system. Data is also rather mixed, with some studies showing reasonable efficacy and others showing almost none. If your patients want to take herbal supplements, it is essential to be diligent about checking their efficacy and interactions with other therapies to ensure safety. The physician should also be clear when discussing current medications to ask specifically if they take herbal supplements of any kind, as many patients don’t consider these to be “medications” and will omit them during history. Of note, turmeric has to be taken with black pepper for better GI absorption.
Weight reduction: A healthy diet and fitness are always recommended. Online guidelines are helpful on topics such as healthy fats, vegetables, avoiding refined sugar, and more. Obesity is a pro-inflammatory state, but it is important not to blame chronic pain problems solely on obesity since patients may still have pain after losing weight. Weight reduction can be a part of that plan, but we should not promise a cure for chronic pain after a patient reaches an ideal weight.
Sleep disturbances: Ironically, sleep improves pain, but pain makes sleep more difficult. If patients complain of sleep disturbances, start with behavioral changes, including improved sleep hygiene (keep a regular sleep schedule, exercise regularly, don’t use caffeine and caffeinated beverages, don’t eat too late at night) and stimulus control (the bed should only be used for two things: sleep and sex, get out of bed if you can’t sleep, wake up at the same time every day, and avoid bright screens before bedtime because they confuse your brain); cognitive behavioral therapy (deal with concerns or worries that may interfere with sleep). Treating sleep disturbance may have a positive effect on the treatment of chronic pain.
Acupuncture: It involves the insertion of very thin needles through the skin at specific points on the body. Acupuncture is a key component of traditional Chinese medicine and can be considered in patients with chronic pain. There are significant difficulties in studying acupuncture, but randomized trials suggest that acupuncture and placebo may have similar efficacy, and both are superior to no treatment.
Pharmacologic therapy – For patients with inadequate analgesia despite nonpharmacologic therapies, we add carefully selected multi-targeted pharmacological therapies based on the type of pain (i.e., nociceptive, neuropathic, central sensitization)
For nociceptive pain, start with non-steroidal anti-inflammatory drugs (NSAIDs) while continuing non-pharmacologic treatments. If that doesn’t work add a topical agent such as lidocaine, capsaicin, or topical NSAIDs. Consider opioid treatment if neither of those works.
For neuropathic pain, start with antidepressants or antiepileptic drugs: tricyclic antidepressants, SNRIs, pregabalin, gabapentin, or carbamazepine in addition to non-pharmacologic therapy. If those medications do not provide relief of pain, then you can consider adding topical agents and then opioids after weighing the risk and benefits. Side effects can be viewed as harmful, but we can use them for our benefit.
Opioids are reserved for people with moderate to severe pain who cannot function. Once you identify a treatment that works for the patient, follow-up visits should be continued to promote behavioral changes, monitor therapeutic response, and treat side effects. A pain contract should also be signed.
Follow-up visits – Schedule follow-up visits to continue educating patients and their families and caregivers, to continue motivational interviewing, and to monitor improvement. Refer patients who are not making enough progress, such as not reaching goals of function and quality of life, to comprehensive pain programs that can use additional modalities such as injections.
Bottom line: Non-pharmacologic options should be considered in the management of all patients with chronic pain. The main non-pharmacologic strategies include physical therapy, psychological therapy, and complementary and integrative therapy. Remember to treat sleep disturbances and obesity as part of your plan. Add pharmacologic agents such as NSAIDs, antidepressants, and anticonvulsants when non-pharmacologic therapies do not help the patient reach their goals. Consider opioids only in moderate to severe pain with loss of function. Opioid prescription is a complex topic that was addressed in episode 31 of this podcast, more than 2 years ago, it is time for an update. Stay tuned, we will talk about opioids soon.
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Conclusion: Now we conclude episode number 125, “Non-opioid Chronic Pain Management.” Non-pharmacologic therapy is proven to be effective in the treatment of chronic pain, especially physical therapy, psychological therapy, and some complementary therapy. Medications can be added to non-pharmacologic therapy, mainly NSAIDs, antidepressants, antiepileptic medications, and more. Opioids can be added in disabling chronic pain, but prescription needs to be done cautiously and watchfully. The treatment of chronic pain may be challenging and daunting at times, but fortunately, we have science to back us up with effective ways to help our patients. So, don’t be discouraged and trust science!
This week we thank Fiona Axelsson, Jesse Lamb, and Hector Arreaza. Audio editing by Adrianne Silva.
Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!
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