Reframing the Treatment of Chronic Pain with Non-Pharmacological Therapy
Submitted by Jordan Flaherty
Tags: addiction chronic Chronic Pain crisis health hospitals insurance pain patients treatment treatment options
Contributing to the opioid crisis is a concern for anyone delivering healthcare, but it does not mean that pain is not an important factor to address. When it comes to acute, severe pain, the best choice may be to prescribe an opioid on a short-term basis, but there is not a sufficient amount of evidence available that supports the use of opioids over a long-term basis to treat chronic pain (CDC, 2016). Studies show that medication is not the only way to treat pain and that pain is not as simple as a number on a scale of 0-10. We need to start utilizing non-pharmacological treatment options to treat the complex issue of chronic pain, in order to combat the opioid epidemic.
The Opioid Crisis and Restrictive Measures
There is a known association between overprescribing of opioids and addiction (Adams et al., 2016). Why don't we just get rid of them all together then? It has been shown that abruptly stopping the availability to opiates can cause patients to seek pain relief from other substances, like heroin. In 2010, Florida tried to restrict oxycodone prescriptions. The restriction led to a 50% reduction in oxycodone prescriptions but increased use of heroin and an increase in overdose deaths (Murray et al., 2019).
The world is deep in this opioid crisis, and some drastic measures need to be taken. In October 2019, the Center for Medicaid and Medicare (CMS) removed pain questions from their HCAHPS questionnaire (CMS.gov, 2019) due to the concern that hospital staff may feel pressured to prescribe more opioids in order to achieve higher HCAHPS scores (Thompson, 2017). After this removal, from 2018-2019, there was a drop of 7% in prescription opioid-related deaths (CDC, 2021).
CMS is not the only entity that has tried to combat the opioid crisis. The Department of Health and Human Services (HHS) has set its sights on five major priorities to combat the opioid crisis including public health surveillance, supporting research on pain and addiction, and advancing better practices for pain management (National Institute on Drug Abuse, 2021). The National Institute of Health (NIH) has also attempted to combat the crisis by finding new ways to prevent abuse, treat misuse disorders, and manage pain all together (National Institute on Drug Abuse, 2021).
The director of the NIH also launched the HEAL (Helping to End Addiction Long-Term) Initiative which funds hundreds of nationwide projects that are targeted toward the understanding, management, and treatment of opioid addiction and also improving treatment options (National Institutes of Health, n.d.).
The Joint Commission and Non-Pharmacological Standards
There are a number of initiatives and government agencies that are actively trying to deal with the opioid crisis. However, so far, the Joint Commission (JCO) has been the only agency who has outright mentioned the use of non-pharmacological pain management options. In a complimentary publication of the Joint Commission, R3, the pain assessment and management standards for hospitals was released. Within this publication are various ways of improving patient safety and quality to Joint Commission-accredited hospitals.
The publication mentions that hospitals must provide non-pharmacological pain treatment modalities (R3, 2017). JCO then offers that non-pharmacological pain therapies have the potential to decrease the number of opioids needed by a patient by working complementarily with medications (R3, 2017). If the Joint Commission is making non-pharmacological pain treatment a standard, then convincing stakeholders of this type of pain treatment's importance shouldn't be too difficult.
Key Stakeholders in Non-Pharmacological Pain Management
A study performed by Mazurenko et al. found that the majority of hospital clinicians believe that hospitals contribute to the opioid epidemic (2020). Those hospital clinicians included hospitalists, nurses, and nurse practitioners.
Nurses are one of the key stakeholders in the utilization of non-pharmacological pain management options. Nurses are at the frontlines of providing direct patient care and improving pain. A lot of the non-pharmacological treatment modalities are those that can be offered to patients by nurses, without the need for a prescription or doctor's approval.
Physicians are another key stakeholder in this process. Without physicians playing an active role in offering complementary therapies, it will be difficult for patients to agree to try other modalities.
Hospital executives are a huge stakeholder as well, because in order for a hospital to stay up to Joint Commission standards, non-pharmacological treatment options must be offered to patients. The hospital executives are also the ones responsible for supplying funding for the alternative treatment modalities. A study on the cost effectiveness of virtual reality by Delshad et al. found that the use of virtual reality was cost-saving, as long as it reduced the patient's length of stay by about 14% (2018).
Patients are a stakeholder in this process as well because it is their body, their pain, and their choice about what treatment they want to pursue. A systematic review done by Fan & Chen found that all studies reviewed reported a significant positive effect of non-pharmacological interventions for pain relief (2020).
Pharmaceutical companies may play a role in this policy because, as previously mentioned by JCO, the use of non-pharmacological therapies may lead to a reduced number of opioids prescribed. A decreased number of opioids may mean a decrease in profit for pharmaceutical companies.
Insurance companies come into play as well, as being the responsible payer for the alternative therapies. A study completed by Bonakdar et al. found that the majority of state insurance coverages do not offer coverage for non-pharmacological pain treatment therapies (2019).
Proven Non-Pharmacological Treatment Options
There are a variety of proven, non-pharmacological treatment options for a variety of sources of pain. Education, therapy, and many other approaches have been shown to be effective, with or without medication, in the treatment of any type of pain (Clauw et al., 2019).
Simply offering cognitive-behavioral therapy, especially in the treatment of chronic pain (Dean, 2021), can help people better deal with their pain. Mindfulness-based stress reduction was found to reduce pain intensity compared to control groups (Kligler et al., 2018). People undergoing manipulation therapy found significant improvement in their low back pain (Kligler et al., 2018).
A study found that acupuncture was actually more effective in the treatment of musculoskeletal pain, headache, and OA pain (Kligler et al., 2018) than normal treatment. There is strong evidence to indicate that massage therapy should be considered as one of the first-line treatment options for low back pain (Kligler et al., 2018). Music therapy has been shown to improve pain when used as an adjuvant approach to pain control (Cole & LoBiondo-Wood, 2014). Lastly, simply exercising has shown promise in the treatment of certain pain (Pollack, 2020).
Rewriting the Guidelines
The CDC currently offers a guideline for prescribing opioids for chronic pain. The guidelines address when to initiate therapy, which opioid to choose including how much and how long, and assessing the risk and harms of prescribing the therapy (CDC, 2016). Instead of focusing on opioid therapy, the CDC should rewrite their guidelines to include non-pharmacological therapies that are proven to work against chronic pain.
Before initiating any opioid therapy, the prescriber can attempt to refer a patient to manipulative medicine, or therapy, to help with their pain. There needs to be a decreased focus on opioids being the only source of pain relief in the hospital and doctor setting. A holistic nursing approach that integrates multiple modalities can be far more effective than relying on a single pharmacological solution.
Barriers and Considerations
There are a variety of things that need to be considered prior to creating this policy change. Patients may be skeptical to these practices, so it is extremely important to educate all parties involved, including the physicians offering these interventions. Becker et al. identified the need for increased patient and provider education about the interventions and also increased advertising to be facilitators of non-pharmacologic pain treatments (2017). Becker et al. also identified that having a positive belief in the non-pharmacological treatment leads to more use (2017).
There is also the issue of current patients who may already have an opioid addiction, who will not want to try the policy change because these patients are simply seeking medications. For these patients, offering the initiation of an opioid agonist can help them with their pain, any withdrawal symptoms, and increase the likelihood that they'll transition to an outpatient treatment center (Donroe et al., 2016).
There is the issue of hospital executives not finding the interventions to be cost effective to fund. If that becomes the case, finding donors to fund the execution of certain treatment modalities may become necessary, or performing quality improvement projects to prove the positive impact may be necessary as well. There is also the issue of insurance companies not covering the alternative therapies, but as these therapies become more utilized, the likelihood of them being covered by insurance becomes higher.
Conclusion
Opioids have the potential for many negative side effects. Negative side effects of opioids include respiratory depression, nausea, vomiting, constipation, confusion, as well as addiction (Cole & LoBiondo-Wood, 2014). By utilizing the above non-pharmacological pain treatment modalities, we can decrease the potential for negative side effects of opioids, while improving patients' pain.
Physicians don't have to prescribe as many opioids. Nurses don't have to administer so many opioids and can actively participate in pain improvement with certain non-pharmacological interventions. Hospital executives can follow JCO's standards by offering non-pharmacological pain treatment modalities. Patients don't have to suffer from the potential negative side effects of the medications, and can have more variety of choice in treatment options.
If hospitals start offering more non-pharmacological pain management options, we can help combat the opioid crisis by decreasing the number of opioids prescribed.
References
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