Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care

Abstract

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Pediatric pain screening identifies youth at risk of chronic pain in sickle cell disease

“…For example, youth in the low‐risk group may be responsive to medication and standard care that integrates education about SCD self‐management, whereas the medium‐risk group may require targeted education about the biopsychosocial impact on pain and introduction to coping skills to facilitate improved functioning. Youth in the high‐risk group may require more intensive, interdisciplinary treatment that combines medical care; psychological services such as cognitive‐behavioral therapy; physical therapy; and integrative treatments such as acupuncture, yoga, or tai‐chi . Therefore, brief and routine screening can allow for early identification of youth experiencing SCD pain and comorbid psychosocial risks and may facilitate early, targeted intervention to help improve pain and functioning.…”

Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care—a Randomized Trial

“…The prevalence of chronic pain conditions in the adult US population ranges from 11 to 47% in large surveys [1][2][3][4][5][6][7][8] ; low back and neck pain, osteoarthritis (OA), and headache are the most common. 9 Underserved and ethnically diverse populations are especially at risk for pain and pain undertreatment, 5,[10][11][12] and these disparities are compounded when limited English proficiency impacts communication. 5 Living with chronic pain is associated with impairment of physical and psychological functioning, [13][14][15] lost productivity, 16 and lower socioeconomic status.…”

“…[27][28][29][30][31][32] A recently updated individual patient data meta-analyses including over 20,000 patients with chronic pain showed acupuncture to be significantly better than sham treatment or usual care with only a 15% reduction in treatment effect at 1 year. 33 Acupuncture therapy is supported or recommended as part of comprehensive pain care 12 by the Agency for Healthcare Research and Quality (AHRQ), 34 the American College of Physicians (ACP), 35 and the Joint Commission (TJC). 36,37 Acupuncture therapy has been predominantly studied in the individual setting 17 ; it has been shown to be effective and feasible for low-income, ethnically diverse, chronic pain patients delivered in community health center settings.…”

Barriers and Solutions for Improving Pain Management Practices in Acute Hospital Settings: Perspectives of Healthcare Practitioners for a Pain-Free Hospital Initiative

“…Clinicians must remain up-to-date on complementary and alternative approaches to provide patients information on these options for pain management. 26) Further study may be required to assess how culture impacts patient and clinician understanding of pain and to tailor pain assessment and management strategies to suit the target population.…”