Evidence-based nonpharmacologic strategies for comprehensive pain care

BY VICTOR S. SIERPINA, MD, ABFM, ABIHM, Director, Medical Student Education Program, WD and Laura Nell Nicholson Family Professor of Integrative Medicine, Professor, Family Medicine University of Texas Distinguished Teaching Professor

Unless you have been living under a log in the woods, you are already aware of the opiate epidemic. The annual toll of lives of 64,000 or more overdoses and deaths exceeds death from car accidents and is now a leading cause of mortality in the United States.

In order to address this public health crisis, the Academic Consortium for Integrative Medicine & Health empaneled a task force led by Drs. Heather Tick and Arya Nielsen along with eight well-respected experts in pain management. This group worked to identify the best-evidenced approaches to pain care that did not include drugs.

A new paradigm is needed as opiate drugs have become the problem, not the solution.

Recent discoveries about central and peripheral processing of pain, hyperalgesia, neuroplasticity, postural issues, repetitive strain, anatomy, social context, and comorbidities are providing us with new actionable ways to classify and manage chronic pain syndromes.

I will summarize here, some of the key findings of this task force especially approaches to pain that ought be included in any comprehensive pain management program. To read the full white paper, just go to the link and locate the PDF in the Project Log section (https://www. /project/Evidence- Based-Nonpharmacologic-Strategiesfor- Comprehensive-Pain-Care-The- Consortium-Pain-Task-Force-White-Paper). It is required reading for all of us who take care of patients with chronic pain and who want to be part of the solution, not contributors to the opiate addiction problem.

The white paper starts off with a section on historical context that examines societal and social impacts of chronic pain, impact on productivity and work, health disparities, the complexity and comorbidities associated with pain, risk and lack of effectiveness of prevalent pain care strategies. This is a call to action by policymakers, regulatory, civic, educational, research, and professional organizations to reverse this dire storm of harm, which has in large part been caused by legally prescribed controlled substances. It is a call for systems change, reinforced in the closing section, to transform the system of pain care to a responsive, comprehensive model in which non-pharmacologic strategies reduce risks and improve patient outcomes.

So what am I to do, as a primary care doctor, when a patient present with pain that is not related to a terminal condition or malignancy? The most common kinds of problems in my practice are headaches, chronic back, and other musculoskeletal pain.

Perhaps the first step is to look at managing functionality, rather than making pain the front stage issue. Some pain levels are tolerable if function in the home and workplace are preserved. Excessive focus on opiates or other pain medications at this stage can lead to a variety of adverse and unintended consequences including workplace absenteeism, presenteeism, and eventually disability. Addiction and its social, economic, and medical consequences often follows quickly on the heels of starting an opiate regime.

The task force searched the literature exhaustively for evidence-based alternatives to drug therapy. They found substantial evidence for modalities such as acupuncture, massage, mind-body therapies, music therapy, guided imagery, and virtual reality assisted distraction in post-operative and acute pain. Similar therapies were found to be applicable in chronic pain and cancer-related pain. Manipulative therapies such as chiropractic and osteopathy were found to be safe and effective. Mind-body therapies, mindfulness, relaxation therapies, biofeedback, and cognitive behavioral therapy were also supported by clinical research as safe and effective for many types of chronic pain.

Movement therapy was another category for managing pain, and such popular techniques such as yoga and tai chi were endorsed as evidence-based. Alexander, Feldenkrais, Pilates, and other movement methods were recommended as additional options.

Finally, lifestyle behaviors, self-efficacy, and nutrition all play an important role in managing chronic pain. The antiinflammatory diet, micronutrients, and regular activity can all contribute to improved pain management and coping with pain. Multimodal approaches should be tried if a single kind of intervention is not sufficient to control pain.

Ultimately, we need a cultural, professional, and systems change in our management of chronic pain. Referral, reimbursement, educational, policy, and educational strategies must align and be deployed along with public awareness to reduce the downward spiral in the care of those with chronic pain. Increasing focus on function, safe and non-invasive, nonaddictive therapies is essential. Hospitals, clinics, and academic centers must build interdisciplinary teams that create a healing environment for those in pain without creating a secondary problem of opiate dependence. Regulatory and public organizations such as JCAH, IOM, DOD, NIH, CDC, VAH, ACP, AHRQ and others concede and increasingly mandate that an informed and revised strategy for pain management be operationalized. Costbenefit analyses cited in this paper show clear savings, rather than “add-on” costs by using non-pharmacologic therapies.

Read this bold call to action and make a change in this fifth vital sign wherever you are. “If not now, when? If not you, who?”