● An inadequate response to medication in terms of either pain relief or functional improvement. ● Evidence of nonmedical or inappropriate use of the medication. If inappropriate use of a prescription medication leads to termination, referral to a provider with specialized skills or experience in dealing with high-risk patients may be prudent. 118,122 to increase awareness of thoughts in order to reduce the severity of painful symptoms using a range of strategies to modify their interactions with their environment. 123 Mind-body therapies describe a broad range of treatments that address a patient’s thoughts, emotions, movement, behaviors, and body awareness. It includes mindfulness-based stress reduction, deep breathing, relaxation, and meditation. Evidence supporting mind-body therapies is of poor quality, often due to the difficulty in studying these therapies, but suggests some benefit. A 2020 meta-analysis found the use of mind-body therapies lead to moderate improvements in pain and small reductions in opioid dose in both acute and chronic pain patients treated with opioids. 123 Acupuncture, originating from traditional Chinese medicine, is one of the oldest healing practices in the world. Acupuncture stimulates specific points in the body, usually by inserting thin needles through the skin. According to the traditional Chinese medicine theory, this regulates the flow of vital energy (called qi) along pathways called meridians. It is recommended by the American College of Physicians to include acupuncture among the first-line non-pharmacological treatments for chronic low back pain. It may be appropriate to consider acupuncture in some cases of pain management. 124 Chiropractic manipulation is a form of manual therapy that involves correcting the alignment of a joint. A meta-analysis of over 6000 patients across 26 trials found that spinal manipulation in patients with chronic low back pain resulted in small short-term reductions in pain, as well as improved functional status when compared with a variety of other interventions including medications and physical therapy. 125 Massage can also be used in the treatment of pain, and while there is limited evidence to support its use, the harms from massage appear to be minimal, and some patients report symptomatic relief, making it a reasonable adjunctive treatment. 126
Another key component is a description of how treatment might be terminated. It is critical to discuss the conditions that could lead to the discontinuation of therapy. Opioids are not curative and have no standard duration of treatment. Termination may become necessary for many reasons, including: 118,122 ● Healing or resolution of the cause of pain. ● Experiencing significant side effects. Non-Pharmacological Pain Management When evaluating the options available to a particular patient for the treatment of pain, providers should maximize the use of nonpharmacologic therapies. Nonpharmacologic therapies can be grouped into several categories: exercise therapy, psychoeducational interventions, mind-body therapies, and physical interventions such as chiropractic manipulation, acupuncture, and massage. Combining therapies may be more effective for maintaining long-term relief than any single treatment. The choice of therapy is based on a number of patient-specific factors, such as the type of pain, preference, cost, access, and patient values. 123 Maximizing the use of nonpharmacologic treatment options, and combining their use when appropriate, can improve pain control and reduce the reliance on opioids. 118 Useful in both acute and chronic musculoskeletal pain conditions, physical therapy helps patients work towards the goal of improved physical function. It involves working with a physical therapist to develop patient-specific exercises that allow patients to feel safe while being physically active, encouraging patients to increase daily activity levels. Physical therapy can also address deconditioning and fear- avoidance seen in chronic pain patients. It has been shown to demonstrate moderate effects on disability and pain while improving quality of life, anxiety, and depression. 123 Therapeutic exercise is low-impact exercise programs, such as aquatic exercise, yoga, or tai chi. Studies show that exercise therapy for chronic pain can reduce pain and improve function with few adverse effects. The American College of Physicians recommends structured exercise, yoga, and tai chi among their other first-line therapies for chronic pain. 123 Psychological therapies are recommended for patients who have pain that impacts their mood, quality of life, sleep, or relationships with others. The most commonly recommended and best-studied psychological therapy for chronic pain is cognitive-behavioral therapy. It addresses the way that a patient’s thoughts interact with their actions, targeting maladaptive behavioral and cognitive responses to pain. Patients are taught
Pharmacologic Treatment of Pain: Non-Opioid Medications Just like the causes of pain, available treatments are also diverse. Pharmacologic treatment options run the gamut from over-the-counter pain relievers to controlled substances, with many alternatives in between. Because of the many different pathologies, it is critical that if one approach fails, another is tried. When it comes to pain management, no single treatment is guaranteed to work as intended. Further,
relief may be found using a combination treatment approach. Milder pain episodes can often be treated using over-the-counter medications including acetaminophen and non-steroidal anti-inflammatory agents (NSAIDs). 118,127
Book Code: CA23CME
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