An Inter-agency Task Force convened by the Department of Health and Human Services (HHS) to recommend best practices in pain care proposed several ways of addressing gaps: 3 • Create clinical practice guidelines to better incorporate evidence-based complementary and integrative therapies into practice. • Improve insurance coverage and payment for different modalities on the basis of the best practices identified in new guidelines. • Improve coverage and payment for multidisciplinary team care coordination. • Expand access to treatment and geographical coverage via the use of telemedicine and other technological delivery methods for psychological and behavioral health interventions. • Increase the number and training of qualified practitioners in behavioral health and other evidence-based complementary and integrative disciplines. • Provide better education as well as time and financial support for primary care practitioners who give patients the sole available pain care in many parts of the country. Another barrier to pain care is the stigma in living with chronic pain, which is often cited by patients and their caregivers as a difficulty worsened by lack of objective biomarkers for pain, the invisible nature of the disease, and societal attitudes that equate acknowledging pain with weakness. 31 Compassion, empathy, and trust within a practitioner-patient relationship are key to navigating these challenges. It can help to offer education to the patient regarding the underlying disease processes of pain and to encourage them to seek help early for pain that persists beyond the expected time frame. When opioids are indicated, it is strategic to counsel patients that opioids are an appropriate part of their pain treatment plan so that the stigma of the societal opioid crisis does not interfere with appropriate treatment and good outcomes for the patient regarding opioid use. 23 Treatment Options for Managing Pain The HHS Inter-Agency Task Force on best practices in pain management categorizes options for pain treatment as medication, restorative, interventional, behavioral health, and complementary and integrative. 3
Medications include opioid and nonopioid pharmacologic treatments. What follows are examples of each (not an exhaustive list) and a brief discussion of the evidence base underpinning these options. Nonpharmacologic Options for Pain A number of evidence-based nonpharmacologic treatments are recommended, either used alone or in combination with other modalities within a treatment plan that is individualized and draws from multiple disciplines (Table 1). 3,32,33 Nonpharmacologic options should not be considered “alternatives” to opioids but are encouraged as part of a comprehensive pain plan in keeping with the evidence base, patient access to competent practitioners, and adequate insurance coverage and reimbursement. Frequently covered modalities for chronic pain include cognitive behavioral therapy (CBT), physical therapy, certain injections, exercise, and electrical stimulation. 32 Patients may find it helpful to combine approaches that include nutritional support, healthy lifestyle changes, patient education, sleep hygiene instruction, and relaxation and visualization techniques. The noninvasive nature and low side effect profile of nonpharmacologic treatments suggest they should be used first and preferentially. Restorative Therapies Physical and occupational therapy are recommended for acute and chronic pain and are best combined as part of a multidisciplinary treatment plan after a thorough assessment. 3 Traction is frequently used as part of physical therapy and, although evidence that it is clinically effective is lacking, the HHS Inter-Agency Task Force suggests it should be investigated separately and considered as a treatment modality for low-back or neck pain. 3 Unfortunately, despite evidence of improved outcomes, use of these physical and occupational therapies are frequently challenged by incomplete or inconsistent reimbursement policies, and policymakers have been asked to look more closely at improving payer polices. 3 There is high-quality evidence that therapeutic exercise improves outcomes over bed rest. 3 Principally investigated as a treatment for spinal pain, therapeutic exercise has been shown to help patients function better and to help them overcome
the anxiety and fear of movement that worsen pain and disability. Transcutaneous electric nerve stimulation research is plagued by a lack of high-quality, unbiased studies, and overall evidence of efficacy is limited. 3 It has been investigated for treatment of acute low-back pain, postpartum pain, phantom limb pain, and knee osteoarthritis, and, despite limited evidence, can be considered among the safer self-care options with appropriate patient education. 3 Massage therapy includes Swedish, shiatsu, and deep tissue or myofascial release types. A systematic review found massage can be effective in the general population for pain, anxiety, and to improve health-related quality of life compared to sham, no treatment, and active comparators. 34 The application of cold and heat is a standard approach in relieving the symptoms of acute pain. Evidence supports use of cold therapy to reduce pain after surgery and heat wraps to relieve pain symptoms and increase function in acute low- back pain. 3 The evidence has not been robust that therapeutic ultrasound is more effective than placebo for musculoskeletal pain conditions; however, recent findings show it can be effective in relieving knee osteoarthritis. 3 Nonrigid bracing may improve function and is unlikely to cause muscle atrophy when used for short periods. 3 Interventional Options Interventional pain management describes a variety of techniques that vary in terms of their invasiveness. Techniques may use image-guided technology to help diagnose and treat sources of acute and chronic pain. Such treatments may help minimize the use of oral pain medication, including opioids, but have risks as well as advantages that should be understood and discussed with patients. Low complexity interventions include: • Trigger point injections, usually composed of an anesthetic like lidocaine, which disrupt the tense bands of skeletal muscle fibers that produce pain and can be used to treat headaches, myofascial pain syndrome, and low-back pain 3 • Joint injections, often of corticosteroid into various joints, which are useful for inflammatory arthritis and basal joint arthritis 3
Table 1. Noninvasive, Nonpharmacologic Approaches to Pain Management 3
Restorative
Behavioral Health
Complementary and Integrative
• Physical therapy • Occupational therapy • Physiotherapy • Therapeutic exercise • Transcutaneous electric nerve stimulation • Massage therapy • Traction • Cold and heat • Therapeutic ultrasound • Bracing • Chiropracty
• Cognitive behavioral therapy • Acceptance and commitment therapy • Mindfulness-based stress reduction
• Acupuncture • Massage, manipulative therapies • Mindfulness-based stress reduction • Spirituality • Tai chi
• Emotional awareness and expression therapy • Self-regulatory/psychophysiological approaches: ° Biofeedback ° Relaxation training ° Hypnotherapy
• Yoga • Reiki
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