Primary care clinicians should know about the range of treatment options available, the types of pain that may be responsive to those options, and when they should be used as part of a multidisciplinary approach to pain management. 37 Clinicians should also be aware that not all nonpharmacologic options have the same strength of evidence to support their utility in the management of pain, and some may be more applicable for some conditions than others. Movement-based options Movement therapies that may be helpful in patients with chronic pain include muscle- strengthening, stretching, and aerobic exercise (e.g., walking, aquatics). Recommended exercise programs typically occur one to three times a week for a total of 60-180 minutes per week, but any regimen must be carefully tailored to a patient’s existing level of physical conditioning, comorbidities, and cognitive status. 38-40 Additional movement-based options include: • Physical therapy supervised by a licensed physical therapist, which can include resistance, aerobic, balance, and flexibility exercises as well as elements of massage, manipulation, or transcutaneous electrical nerve stimulation. • Tai chi , a mind-body practice that combines controlled movements, meditation, and deep breathing. “Chair tai chi” can be an option for patients with limited mobility. • Yoga , exercises or a series of postures designed to align muscle and bones, and increase strength and flexibility. It can also relax mind and body through breathing exercises and meditation. Gentler forms of yoga that may be more appropriate for older patients include Iyengar, Hatha, or Viniyoga. Although these interventions may cause muscle soreness, increased back pain, or falls, movement- based options are generally considered safe. 40 Weight loss Some pain syndromes, such as knee osteoarthritis, are worsened by obesity. For some patients, pain due to this condition is improved by reducing body weight because of reduced loads and physical stresses on the affected joints. The goal of body weight reduction is a baseline weight loss of 7%-10% by calorie reduction and increased activity using a balanced diet with less than 30% of calories from fat, 15%-20% from protein, and 45%-60% from carbohydrates. 41
Passive options Acupuncture involves the stimulation of specific points on the body, most often involving skin penetration with fine metallic needles manipulated by hand but sometimes also including electrical stimulation or low intensity laser therapy. Potential adverse events include minor bruising and bleeding at needle insertion sites. 42 Massage is the manual manipulation of the body to promote relaxation, reduce stress and improve well-being. Handheld devices may also provide relief for some patients. Some patients may report muscle soreness. 43 Transcutaneous electrical nerve stimulation (TENS) is a machine that generates mild electrical pulses which are applied cutaneously. The electrical stimulation from TENS may block or disrupt pain signals to the brain, reducing pain perception. TENS machines can be used at home or in conjunction with other interventions like physical therapy. Cognitive and behavioral options Cognitive behavioral therapy (CBT) is a structured, time-limited (typically 3-10 weeks) intervention focused on how thoughts, beliefs, attitudes, and emotions influence pain and can help patients use their minds to control and adapt to pain. This therapy includes setting goals, often with recommendations to increase activity to reduce feelings of helplessness. 44 Meditation Mindfulness meditation programs typically include a time-limited (8 weeks; range 3-12 weeks) trainings with group classes and home meditation. The objective is to inculcate a long-term practice that helps patients refocus their minds on the present, increase awareness of self and surroundings, and reframe experiences. 45,46 Non-opioid drug approaches A wide range of medications can be used to
Acetaminophen Lower doses of acetaminophen are recommended to decrease risk of side effects. Patients should not exceed 1000 mg in a single dose. The maximum recommended dose for healthy adults is 4000 mg/day. 47 The most severe potential side effect of acetaminophen is liver toxicity. Acetaminophen is the most common cause of acute liver failure, accounting for 46% of all cases. 48 Patients should stay within recommended doses to help prevent side effects and should only be prescribed one acetaminophen-containing product at a time. NSAIDs Chronic use of NSAIDs may be limited by gastrointestinal (GI) toxicity, including GI bleeding, upper GI symptoms, ulcers, and related complications. For high-risk patients, including the elderly, patients on warfarin or aspirin, and those with coagulopathies, adding a proton pump inhibitor (PPI) may help reduce the risk. 49,50 In addition to GI side effects, NSAIDs have been associated with an increased risk of renal and cardiac complications. Side effects with NSAIDs are typically lower with topical formulations. Some early trials suggested that COX-2 inhibitors, as a class, were associated with higher risks for myocardial infarction and stroke compared to other NSAIDs, and the COX-2 inhibitor rofecoxib (Vioxx) was removed from the market in 2004 because of such concerns. 51 More recent trials and meta-analyses, however, provide strong evidence that the risks of CV events with celecoxib are no greater than those of other NSAIDs, and in 2018 two FDA advisory panels recommended that the FDA change its advice to physicians regarding celecoxib’s safety. 52 Selective serotonin norepinephrine reuptake inhibitors SNRIs such as duloxetine, venlafaxine, and milnacipran are characterized by a mixed action on norepinephrine and serotonin, though their exact mechanism of action for pain reduction is unknown. These agents affect the descending pain pathways to facilitate pain relief. Side effects (e.g., nausea, dizziness, and somnolence) may limit treatment. Monitoring is suggested for blood pressure (duloxetine and venlafaxine), heart rate (venlafaxine), and drug interactions (duloxetine). SNRIs can be very helpful in patients who have central sensitization. TCAs TCAs inhibit reuptake of norepinephrine and serotonin. These agents act on descending pain pathways, but their mechanism of action for pain relief is unknown.
treat pain, including: • Acetaminophen • NSAIDs (oral or topical) • Antidepressants ° serotonin and/or
norepinephrine
reuptake inhibitors
° °
tricyclic antidepressants (TCAs)
selective serotonin reuptake inhibitors (SSRIs)
• Anticonvulsants • Topical lidocaine or capsaicin • Cannabinoid-based therapies • Ketamine
48
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