EXECUTIVE SUMMARY

Healthcare providers are moving away from opioid-based pain management strategies to evidence-based social, behavioral, and psychological methods of helping people cope with chronic pain.

• Exercise is a first step for patients experiencing both acute and chronic pain.

• Relaxation techniques, including meditation, can work for many people.

• The National Academy of Medicine and other agencies have posted many pain management strategies online.


The proliferation of opioids and the rise of opioid addiction and deaths that surpass automobile deaths in the United States have led to an era when doctors see the risks of opioid prescriptions outweighing the benefits.

In this new reality, physicians will not prescribe opioid medication as often as in the past, which means patients who suffer from chronic pain might need nonmedication coping methods.

“Now, there is a rush to get everyone off opioids,” says Robert D. Kerns, PhD, professor of psychiatry, neurology, and psychology at Yale University in New Haven, CT. Kerns also is director of mentoring and career development at the Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center at VA Connecticut Healthcare System.

The risk is that medical care will return to the decades when it was difficult to get opioids for patients who were not at the end of life, he says.

“There’s such a backlash of opioids that’s problematic,” Kerns says.

For the past 20 years, people in chronic pain would go to their doctors for opioids.

“Their pain was not resolving, and it might not be resolving for psychological reasons,” says Michael Coupland, CPsych, RPsych, CRC, network medical director for Integrated Medical Case Solutions (IMCS) Group in West Palm Beach, FL.

Once these patients take opioids regularly, they become dependent on the medications, he adds.

Case managers will need to learn more about integrated strategies to helping patients cope with chronic pain.

“The importance of nonpharmacological approaches is increasingly understood,” Kerns says.

Coupland and Kerns offer these suggestions for case managers:

• Help patients focus on pain management rather than a pain cure. “Our culture overemphasizes the idea that for every problem we identify there is a cause and solution,” Kerns says.

“That’s not the way we think about most chronic diseases; the idea is management,” he explains. “How do you manage the disease and symptoms and negative impact?”

For example, patients with arthritis might judiciously use nonsteroidal anti-inflammatory drugs, so long as they can tolerate them and do not experience problems with kidney function, Kerns says.

• Make exercise a top priority. “The number-one thing to do for pain is to keep moving and exercise, despite the pain,” Kerns says.

In 1997, Australia implemented a public health initiative called “Back Pain: Don’t Take It Lying Down.” Its purpose was to urge people to move around and exercise when they experienced back pain, Kerns says.

“It resulted in huge government savings in terms of workers’ compensation claims,” he adds.

The campaign’s main message was that chronic back pain patients could do a lot to help themselves. It was the first study to show that mass media could be used to reduce costs related to back pain. (More information on the initiative is available at: http://bit.ly/2Ja2c41.)

Case managers might remind patients to pace themselves when exercising, Coupland notes.

“Don’t get into an all-or-nothing approach,” he says. “People think, ‘I’m having a good day, so I’ll go out and garden and mow the lawn,’ and then they pay for it later.”

Instead, chronic pain patients should identify their limit to physical activity, take breaks during exercise, and go back to it — extending those limits at their own pace, Coupland suggests.

• Promote relaxation techniques. Any type of relaxation or distraction can help people in chronic pain, Coupland says.

“When you’re in pain, you tend to tighten up muscles and recruit other muscles. Relax your body and let pain roll over you and let it go,” he says. “Suggest prayer or meditation or peaceful music to patients.”

• Seek telehealth and technological strategies. Talk therapy via phone or video are strategies that can help people with self-management of chronic pain.

There are web-based self-management tools, and smartphone apps are helping case managers guide patients through online and technology-driven solutions, Kerns says.

Some apps use gaming techniques to help children with headache pain and abdominal pain, he notes.

One strategy for adults involves an interactive voice response in a phone-based intervention.

“Our group at VA Connecticut developed something called COPES, which is a phone-based intervention,” Kerns says. “They get a manual in the mail or online, and the manual teaches them to use a phone to report their daily personal goals or skills practice, and it follows through a set of skill-training modules.”

The researchers followed patients with chronic back pain, using an interactive voice response via phone. Patients could report their symptoms, functioning, and how they coped with pain. After sending in their information, patients would receive a recorded message with feedback.1

Pain patients reported their daily progress on goals, using a scale of 0 to 9. After reporting their results, patients can retrieve personalized feedback from a therapist. They can see a picture and hear the therapist’s voice as he or she tells the patient how they’re doing on their goals.

The therapist role could be a care manager. Feedback is recorded, not live, and it works, Kerns says.

“It’s not inferior to having people come to 10 weekly sessions with a psychologist,” he says. “People were more adherent, meaning they did more modules on the phone. One reason could be they didn’t have the burden of traveling to a site like a VA medical center, where they struggle for parking and then wait to see a doctor.”

The virtual feedback is scripted and doesn’t respond to patients’ complaints. Patients rate the relationship with the virtual therapist as highly as they rate their relationship with the in-person therapist, he adds.

• Check out evidence-based websites on chronic pain. In June 2011, the National Academy of Medicine (formerly the Institute of Medicine) issued a report that is cited often as a blueprint for how the healthcare industry can change the way it deals with chronic pain. Titled “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” the report addresses pain as a national challenge that affects 100 million Americans and costs more than $600 billion each year in medical treatment and lost productivity. (The report is available at: http://bit.ly/2S8nJOF.)

The following are some other government and professional resources about chronic pain:

• The Substance Abuse and Mental Health Services Administration – Health Resources & Services Administration (SAMHSA-HRSA) Center for Integrated Health Solutions has a section on pain management, with links to an opioid prescription checklist, a National Pain Strategy, the PainEDU website, a cognitive therapy paper, and guidelines on how to manage chronic pain in adults with or in recovery from substance use disorders, available at: http://bit.ly/2yPL5Qy.

• Project ECHO is a lifelong learning and guided practice model that provides pain experts via videoconferencing, available at: https://echo.unm.edu/.

• The PAINS project of the Academy of Integrative Pain Management integrates biopsychosocial pain care with patient-centered medical homes and accountable care organizations, available at: http://bit.ly/2PMPCdM.

• The Comprehensive Pain Rehabilitation Center of the Mayo Clinic, founded in 1974, provides rehabilitation services to people with chronic noncancer pain. The three-week outpatient program helps patients learn what they can control about their pain when a cure is not possible. It stresses minimization of pain behaviors, relaxation, eliminating use of pain drugs, daily exercise, stress management techniques, and emotional coping techniques. More information can be found at: https://mayocl.in/2Amsrlk.

REFERENCE

1. Heapy A, Higgins D, Goulet J, et al. Interactive voice response-based self-management for chronic back pain: the COPES noninferiority randomized trial. JAMA Int Med. 2017;Epub ahead of print. Available at: http://bit.ly/2RayvCU.