Resources

  1. Niknejad, B.,et al (May, 2018), Association Between Psychological Interventions and Chronic Pain Outcomes in Older Adults: A Systematic Review and Meta-analysis.  JAMA Intern Med. 2018 Jun 1;178(6):830-839. doi: 10.1001/jamainternmed.2018.0756  https://www.ncbi.nlm.nih.gov/pubmed/29801109
  2. Centers For Disease Control:  Treating Chronic Pain Without Opioids (Expires 8/4/2019) https://www.cdc.gov/drugoverdose/pdf/training/Accreditation_WB2859_TrainingModule2_Nonopioid-a.pdf  
  3. Chou R, et al (2017). Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):493-505. doi: 10.7326/M16-2459. Epub 2017 Feb 14.  https://www.ncbi.nlm.nih.gov/pubmed/28192793
  4. Patient Resource: Arthritis Foundation https://www.arthritis.org/living-with-arthritis/pain-management/tips/warm-water-therapy.php 

Transcript

Dr. Frank Domino:
Carrie is here for her three month followup, to discuss her osteoarthritis pain and how it's affecting her life. She is 77 years old and recently widowed. She feels that the pain of her osteoarthritis is keeping her from what she likes to do. She had been moderately active in the past, golfing, walking, and caring for her grandchildren. Her pain today is a three to four over ten, and sometimes it gets as high as six over ten, while awake. She has taken acetaminophen and NSAIDs, but does not want to rely on them, and she trusts you. What else can she do besides taking these meds to treat her chronic pain? And she wants nothing to do with opioids.

Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. And joining me today to talk about treating chronic non-cancer pain is Jill Terrien, Associate Professor and Director of Nurse Practitioner Programs at the University of Massachusetts Medical School's Graduate School of Nursing. Jill, thanks so much for bringing this forward.

Jill Terrien:
Thank you for having me, Frank.

Dr. Frank Domino:

So Carrie has got some issues that I think we can all identify with. Many of our patients are in their 70s, probably developing some RSD osteoarthritis, and they've heard the news that they don't wanna take chronic medications for their pain. Tell us a little bit about how chronic pain is defined in seniors.

Jill Terrien:

Sure, will do. Anybody over the age of 60 is considered to be in the older adult category. Also chronic cancer pain is anything that persist longer than three months. And in this episode today, we're gonna talk specifically about chronic non-cancer pain, and we're gonna talk about the typical types of pain are mainly musculoskeletal in this age group. And I also want to point out that we are not including headache pain in our discussion today because, consistent with the cochrane review, that it was also a pain they did not include in their chronic pain discussions.

Dr. Frank Domino:

Okay. So chronic pain is anything that lasts more than three months. And for our discussion today we're not talking about headaches. What can we say about the non-pharmacologic management of chronic pain? Is it important? What does the data support?

Jill Terrien:
So the data supports that multi-modality, essentially more than one type of therapy, is very effective. And multi-modality means two or more therapies, okay? So think about exercise as a category, and exercise you can include, physical therapy, you could include any type of water therapy, and that might be from warm showers, all the way to walking in a pool, taking a swim class in a pool, which we know is joint supportive, there's a lot of data on that to keep people moving. Also, other things, yoga, walking in the neighborhood, it could be a massage if they're a person that has access to that. So basically anything more than two modalities seems to be... Not one thing is gonna be the cure-all, and it's gonna be different every day for the patient.

Dr. Frank Domino:

So multi-modality, possibly something social if they can. Where does medication fit in, and what are some other psychological interventions we can recommend?

Jill Terrien:

Oh sure. So let's talk about medication first. Basically, pharmacologic options. And Carrie has talked about this in her visit today, that she's tried NSAIDs and she has tried acetaminophen. They definitely play a role, I think they're an option. What I would look at with the patient is, is it somebody that's got a fear of medication, and how many medications are they already on, and what's it gonna interfere with? And side effects. You have to think about NSAIDs, GI upset, kidney function, as side effects. So I think there's a role for them in the multi-modalities of the other things that you're going to actually prescribe with your patient. So let's talk about the psychological therapies that are a possibility. And that is in this episode the article by Nick Najad, The study. We're gonna talk about the psychological interventions and how they relate to chronic pain outcomes in older adults, so over age 60.

And what was found in this, and it was specifically looking at Cognitive Behavioral Therapies as a large... I'm gonna call it a large class because there are many different modalities. But mainly what they found is they looked at a meta-analysis, it included 22 RCTs, 2,600 patients, their average age was 72, and 69% of them were female. And they looked at various pain types, mainly musculoskeletal. So back, knee, osteoarthritis, and RA, and mixed types also. Very important, they excluded the cancer population and the headache population, and the average intervention with these therapies together was about nine weeks, and it worked out to about eight treatment sessions. And when they looked at outcome measures, the majority of the studies, exactly 21 of the 22, looked at pain intensity, and that's what they reported out on.

Dr. Frank Domino:
You were gonna talk a little bit about the psychological modalities, including Cognitive Behavioral Therapy and group therapy. How influential were they in outcomes?

Jill Terrien:
They were very influential, but it was modest, alright. And so to talk about the different types of therapy, it's actually, again, as I spoke at the beginning, a large class. You've got behavioral coping skills training, cognitive coping skills training, restructuring cognition, behavioral activation, and actually one of the categories was acceptance, okay? And so what they found is, is that overall, Cognitive Behavioral Therapy can help patient cope with symptoms that become learned and an expected pattern. So you're trying to change that. And I'm going to call it CBT, Cognitive Behavioral Therapy, as a group showed a small but significant decrease in pain intensity in the intervention group. So what they did is, they looked at interventions and controls obviously, and it remained lower, the pain intensity, for about six months, but not longer. Interesting also, they found that group based therapy demonstrated stronger results. And what they think that could have been due to is the fact that you're sharing, you have public commitment, peer support, and that there's some social facilitation to this.

Dr. Frank Domino:

So it sounds like multi-modal is the approach we should have for chronic non-cancer pain, and that we need to really consider behavioral changes and a structure, either through CBT or through some sort of group based therapy. But realistically in my practice, it's hard to find Cognitive Behavioral Therapy, who are gonna take my patients for eight visits, and I have never even thought about finding group therapy. What do you recommend?

Jill Terrien:

So I think that if you have... And it's also gonna depend on what the patient has access to in their health plan, right? So if you're thinking about access to CBT and depending on where you live, I would suggest you do a simple search and see what's in the area. And if it's something I wanted to explore further, I would actually call that provider and talk to them about what they offer, 'cause this is something that you're gonna basically prescribe to your patient. So there is going that route. On a lesser route, there are apps for everything, and I think that there are mindfulness based apps and there are other apps that can work on the various therapies that are mentioned in this study that you can actually work with your patient on. It's really gonna depend on the level of patient engagement. I think in Carrie's case, you've got somebody that you've been seeing, she trusts you, she's already got a fair amount of activity going on, she's playing golf, and we don't want to limit her quality of life. It's all about the quality of the patient.

So I would take Cognitive Behavioral Therapies as an option, and looking at the many different ways that they can be done, anywhere from muscle relaxation or to meditation and mindfulness, all the way to the way patients think about their pain and what their day looks like. 'Cause if you think about somebody they already know they're gonna be in pain, they already know they're gonna have a bad day, how can we change that thought process?

Dr. Frank Domino:
I love the thought that we need to be expanding our approach to treating chronic pain to include behavioral modalities as well as the patient. We both have a responsibility there. When we're quick, we're busy, we write a prescription, they're out the door. That may or may not be the best way to approach it. In this case, this data shows that we as well as the patient have to change the way we think about and care for chronic non-cancer pain. Well Jill, thank you very, very much. We'll have a variety of resources on the activity page that will help you find both digital resources to locate CBT providers in your area, as well as some online tools that the patient can use to help solve problems on their own. Thanks again, Jill.

Jill Terrien:
Thank you, Frank. Practice pointer, in treating patients with chronic non-cancer pain, think about using behavioral therapies that can improve their quality of life.

Dr. Frank Domino: 
Battling burnout. When you approach patients with chronic non-cancer pain, consider reframing your thoughts about their care, including referring them for behavioral health interventions in addition to pharmacologic treatment. Join us next time when we discuss the risk from medications that can induce depression. And for more timely, relevant, and practical medical education, check out pri-med.com