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The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop (2019)

Chapter: 2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage

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Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
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Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 7
Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 8
Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 9
Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 10
Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 11
Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 12
Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 13
Suggested Citation:"2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage." National Academies of Sciences, Engineering, and Medicine. 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25406.
×
Page 14

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2 Workshop Context: Lived Experience, Provider Perspectives, and Current Patterns of Usage Highlights • A substantial gap exists between scientific evidence and clinical practice for pain and the decisions people make about how to manage their pain (Cherkin, Veasley). • Practitioners, like patients, face a significant gap in measuring and understanding pain, and in assessing the effectiveness and po- tential harms of treatments (Ryan). • Effective pain management requires understanding and treating the multidimensional, including biopsychosocial, aspects of pain (George, Turk). • Placebo responses and interindividual variability in pain thresh- olds and response to treatment may confound evaluations of the effectiveness of pain treatments (Kroenke, Turk). • Currently available methods of assessing pain do not fully capture an individual’s experience of pain (Turk). • Claims-based data show that nonpharmacological therapies for pain account for only a small percentage of total costs (Elton). • When a pain patient’s first point of contact is a physical therapist, chiropractor, or acupuncturist, the odds of early and long-term ex- posure to opiates is markedly reduced (Elton). • Low-income populations experience higher rates of pain, disabil- ity, and comorbidities, but have less access to pain management resources, including nonpharmacological treatments (Thorn). NOTE: These points were made by the individual speakers identified above; they are not intended to reflect a consensus among workshop participants. 5 PREPUBLICATION COPY: UNCORRECTED PROOFS

6 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT LIVED EXPERIENCE AND PROVIDER PERSPECTIVES To ensure that patient and provider experiences were central to the workshop discussions, the workshop opened with perspectives from a per- son living with chronic pain and a family physician. According to Christin Veasley, director of the Chronic Pain Research Alliance, chronic pain is the leading cause of disability worldwide and a major contributor to the rising number of suicides (Petrosky et al., 2018). Yet both Veasley and Daniel Cherkin noted that a substantial gap exists between the scientific and clinical understanding of pain and the decisions people make about how to manage their pain. This gap, said Veasley, arises from multiple factors: an insufficient workforce to address chronic pain; the paucity of team-based medical homes; the classification of pain disorders by symp- toms rather than mechanisms; the lack of objective measures of pain; insufficient high-quality evidence about the efficacy of both pharmacolog- ical (e.g., opioids) and nonpharmacological (e.g., massage) treatments for pain; and insufficient data on risks, benefits, and cost-effectiveness of the various treatment alternatives. Patients living with chronic pain face several decisional dilemmas, said Veasley. These include (1) how to evaluate which nonpharmacologi- cal treatment options may work when, for some approaches, little evidence exists to inform this decision; (2) how to choose the optimal combination of safe and effective treatments; and (3) how to choose the optimal modal- ity, type, or technique within each selected treatment (e.g., the type of mas- sage that would be most likely to provide pain relief). Veasley suggested that by developing research questions based on the decisional dilemmas faced by patients, the field could generate an evidence base, improve re- imbursement, improve outcomes, and reduce uncertainty. One reason for the low level of evidence available for nonpharmaco- logical approaches to pain management is the variability in frequency, du- ration, and type among studies, said Veasley. Another problem is that in order to systematically and quantitatively review data from studies, out- comes must be assessed in a comparable manner, which is complicated by the fact that chronic pain may vary substantially from day to day and week to week and by limitations of the scales used for assessing pain. The fre- quent presence of comorbidities adds further complications given that pa- tients may be receiving many different therapies for pain and nonpain conditions. All of this variability makes it hard to know exactly what is or is not working. PREPUBLICATION COPY: UNCORRECTED PROOFS

WORKSHOP CONTEXT 7 Moreover, she said, the experience and management of pain varies ac- cording to the underlying conditions that are contributing to a person’s pain. For example, managing pain in a person with new-onset osteoarthri- tis is going to be very different from managing the pain of a person with diabetic neuropathy who also has obesity and a sleep disorder. Mark Ryan, a family physician at Virginia Commonwealth Univer- sity, added that providers face other challenges when trying to manage patients’ pain. The national conversation on pain management did not begin to shift until the early 2000s, shortly after Ryan began his residency. The Joint Commission established standards for assessing and treating pain in 2001 (Baker, 2017; Phillips, 2000), but Ryan said it was challeng- ing to assess pain using the scale that asks a patient to rate their pain on a scale of 0 to 10, rather than using metrics that assess global function, qual- ity of life, or other relevant aspects of the pain experience. Practitioners, like patients, face a significant gap in measuring and understanding pain, and in assessing the effectiveness and potential harms of treatments. More- over, treatment in the early 2000s was almost completely focused on med- ication, he said. The idea of integrative and comprehensive care that includes behavioral health and physical therapy was not included as part of physician training. When Ryan moved to a rural practice in 2003, other challenges be- came evident, including the lack of local resources for pain management and limited access to pain management specialists. Now in his current po- sition in Richmond, Virginia, he faces different challenges—for example, 40 percent of new adult patients in his practice lack insurance, are covered by the system’s indigent care plan, and have limited access to nonpharma- cological therapies. Although he can make referrals for physical therapy or other services, patients face practical barriers that limit access to those services, such as transportation challenges and concerns about taking time off work to go to appointments on a consistent basis. Outside of the health system, even insured patients face significant challenges. Examples in- clude pain management programs that limit the type of insurance they ac- cept, specialists who focus primarily on procedures such as nerve blocks or epidural injections, and the lack of an integrated pain service. Concerns about opioid use have exacerbated the difficulties providers experience in caring for patients with pain, said Ryan. Taken together, these challenges have led to dissatisfied and unhappy patients with signif- icant concerns, and dissatisfied, unhappy providers who lack the tools they need to manage their patients’ pain appropriately. There are also pressures PREPUBLICATION COPY: UNCORRECTED PROOFS

8 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT at the health system level to manage chronic pain in an expeditious manner while also caring for patients’ other primary care needs. Ryan expressed his hope that the workshop would identify actionable and practical strategies to address pain management in primary care set- tings, outline evidence-based and effective approaches to chronic pain management that do not rely on opioids or other medications, and encour- age research focused on improving chronic pain management in primary care settings. He also advocated for efforts to improve provider–patient communication regarding treatments and goals for managing chronic pain using collaborative and holistic approaches that encourage shared decision making. Veasley added that a paradigm shift is needed wherein all relevant stakeholders come together at the genesis of a research project and work collaboratively throughout it to bridge the translational divide between basic science and patient care. In addition, research aims that matter to decision makers—including, patients, clinicians, and payers—are needed to ensure successful execution of rigorous science and to promote the adoption of findings into clinical care. BACKGROUND ON PAIN AND NONPHARMACOLOGICAL PAIN MANAGEMENT A recent analysis of the burden of disease in the United States found that 5 chronic pain conditions account for more disability than the 12 lead- ing medical conditions (see Figure 2-1), said Kurt Kroenke, chancellor’s professor of medicine at Indiana University and a research scientist at the Regenstrief Institute (Murray et al., 2013). If depression and anxiety are added to the list of pain conditions, which are comorbid in 30 to 50 percent of people with chronic pain, the burden is even greater. Moreover, most peo- ple with chronic pain have pain in multiple body sites (Kroenke et al., 2013). The burden of pain comes not only from the individual perception of pain itself, but from how it affects other aspects of life, including social roles, vocation, and health care seeking, said Steven George. Understanding this complexity is an essential first step in both treating and managing pain. PREPUBLICATION COPY: UNCORRECTED PROOFS

WORKSHOP CONTEXT 9 FIGURE 2-1 Years lived with disability (YLDs). NOTES: In the United States, pain accounts for 9.7 million YLDs in comparison with 8.8 million YLDs for the 12 leading medical conditions. COPD = chronic obstructive pulmonary disease. SOURCES: Presented by Kurt Kroenke, December 4, 2018; adapted from Murray et al., 2013. Understanding Pain and Pain Management George described pain using the analogy of an onion, with the layers being nociception, individual experience, and impact (see Figure 2-2). At the center of the onion is nociception, the nervous system’s response to painful stimuli. Nociception is embedded within other layers of the onion that comprise the individual’s experience of pain such as the beliefs, emotions, and coping strategies that introduce tremendous variability in how pain is experienced. All of these factors contribute to the impact pain has on other aspects of a person’s life. It was no surprise, George added, that when the Institute of Medicine published its report Relieving Pain in America they concluded that pain is a major driver of health care, disability, and reduced quality of life (IOM, 2011b). PREPUBLICATION COPY: UNCORRECTED PROOFS

10 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT FIGURE 2-2 Understanding the layers of pain. SOURCE: Presented by Steven George, December 4, 2018. Treating pain is different from managing pain, said George. Individual pain treatments target nociception, while pain management addresses mul- tiple layers. Typically, a patient’s first contact with a health care provider trained in conventional medicine leads to diagnosis and drug treatment, with management of pain through nonpharmacological and other ap- proaches only introduced later. Recent changes in the guidelines for how pain is managed aim to shorten that interlude, moving nonpharmacological care closer to the first contact point through more cohesive and integrated management pathways, said George. A large therapeutic armamentarium for pain exists, including medica- tions, surgical procedures, physical modalities, and complementary and multidisciplinary approaches, said Dennis Turk, director of the Center for Pain Research on Impact, Measurement, & Effectiveness (C-PRIME) at the University of Washington. The problem, he said, is that for any of these approaches, evidence of effectiveness is modest (Moore, 2013). Kroenke added that the limited effectiveness of pharmacological treatments is true for both opioids and non-opioids (Krebs et al., 2018). While opioids and non-opioids both showed modest benefits in a recent randomized con- trolled trial for people with moderate to serve chronic pain or hip or knee osteoarthritis, opioids have higher rates of side effects. Moreover, Kroenke noted that in multiple trials for different types of chronic non-neuropathic pain, there is insufficient evidence supporting cannabis as an analgesic (Hill, 2015; Nugent et al., 2017). Possible explanations for the lack of substantial benefits for pain treat- ments include an almost exclusive reliance on the biomedical model of pain and a focus on managing pain itself rather than managing the person PREPUBLICATION COPY: UNCORRECTED PROOFS

WORKSHOP CONTEXT 11 who has pain, said Turk. The biomedical perspective assumes that pain is a signal of injury or some structural pathology; that removal of the prob- lem may be possible through some mechanical fix; and that treatment con- sists of symptomatic relief alone. Turk used the example of fibromyalgia to illustrate the problem of approaching a pain condition with symptomatic treatment. A checklist of 43 symptoms is used to evaluate patients with fibromyalgia, and the average patient endorses 33 of these symptoms. A single treatment would almost certainly be insufficient to deal with the fatigue, pain, cognitive and emotional problems, and many other symp- toms reported by patients, he said. Placebo responses—the perceived improvement in symptoms result- ing from an inactive treatment—can also complicate evaluations of the ef- fectiveness of pain treatments. Kroenke said that placebos have been shown to reduce pain by 30 to 50 percent. Placebo responses have biolog- ical underpinnings mediated by overlapping pain circuits (Kroenke and Cheville, 2017). Although placebo effects can undermine the ability to demonstrate effectiveness of the investigational treatment in clinical trials, Kroenke said these effects should be maximized in clinical practice. Other important factors contributing to the modest effectiveness of pain treatments is interindividual variability in pain thresholds, response to various treatments, and psychosocial characteristics that influence the experience of pain and the response to treatments, said Turk. Patients also vary in terms of the relationship between objective evidence of pathology and how intensely they experience pain (e.g., patients with the same extent of tissue pathology respond in widely different ways to the same interven- tions) (Gerbershagen et al., 2013). Thus, objective pathology alone makes it challenging to predict a person’s pain experience and response to treat- ment. Furthermore, how much pain a person experiences does not neces- sarily equate to his or her functional limitations, Turk added. Assessing an individual’s pain is also fraught with problems, said Turk. Objective information, self-reports, functional performance, and be- havioral observations may all be useful, but are poorly correlated with one another and highly variable from person to person. Turk argued that in assessing pain, biological factors are important, but must be considered along with the individual’s history, attitudes, beliefs, emotions, behaviors, and emotional and financial resources. Moreover, to maximize therapeutic effectiveness, clinicians need to determine how best to facilitate, encour- age, and motivate patients for self-management when a cure is not possi- ble. In addition, Turk said the field needs to develop and evaluate new treatments and regimens that address pain and comorbidities and prevent PREPUBLICATION COPY: UNCORRECTED PROOFS

12 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT misuse and disability; determine what works for whom; evaluate combi- nation treatments; and investigate strategies to facilitate maintenance and generalization of treatment benefits and relapse prevention. Providing Complementary and Integrative Health Approaches to Different Populations in the United States David Elton, senior vice president of clinical programs at Optum, pre- sented claims data to describe usage patterns for pharmacological and non- pharmacological pain treatments, noting that claims-based data do not fully reflect usage because they are blind to out-of-pocket expenditures for many nonpharmacological therapies, such as acupuncture, chiropractic services, and massage, and to non-covered services such as yoga, virtual reality, and mindfulness. Claims-based data are also affected by other dis- tortions such as incorrect coding, capitation, and other factors. Nonethe- less, and keeping these caveats in mind, Elton said the data from UnitedHealthcare/Optum show that spending on nonpharmacological therapies focused on pain across commercial, Medicare, and Medicaid en- rollees totaled about $3.4 billion, or 2.4 percent of all costs in 2017. He noted that Medicare and Medicaid populations encounter increased cover- age constraints because most states provide limited to no coverage for ac- upuncture and chiropractic care. Using a technique that takes claims data and creates “episodes of care” as a means of understanding spending by diagnostic condition, Elton showed that musculoskeletal complaints are responsible for about 16 per- cent of costs as well as most prescriptions for opioids and opioid-containing medicines, with back pain being the most frequent complaint. Elton and colleagues have looked at how a person’s first point of con- tact after the onset of back pain influences the use of nonpharmacological therapies and opioid use; although, Elton noted that they were not able to adjust for factors that might confound the association between the type of first contact point and opioid use. What they found was that when the first point of contact was a physical therapist, chiropractor, or acupuncturist, the odds of early and long-term exposure to opioids was markedly re- duced. He added that while the guidelines suggest that chiropractic manip- ulation has an important role to play, patients receive this care only if they start with a chiropractor. The same is true for acupuncture, massage, and other nonpharmacological therapies, said Elton, calling this an unaccepta- ble level of variation in care delivery. He added that patients’ decisions PREPUBLICATION COPY: UNCORRECTED PROOFS

WORKSHOP CONTEXT 13 about who will be their first point of contact vary considerably due to in- dividual preferences and how the pain manifests; however, all providers should be aware that these other therapies are indicated and preferred over opioids for most back pain. Elton added that an economic model on the value of these therapies indicated that if the front-line use of chiropractic or physical therapy could be increased from 30 to 50 percent in 2 years, more than $200 million could be saved per year. He suggested that simple changes in coverage and practice could achieve these savings, adding that he and his colleagues will be testing this idea over the next couple of years. Reducing Disparities in Pain Management Managing pain is especially difficult in low-income populations for multiple reasons, said Beverly Thorn, professor emeritus of psychology at the University of Alabama. Although these populations have higher rates of pain, disability, and comorbidities, they lack access to health care re- sources and consequently get less treatment for pain, she said. Access lim- itations may also affect other subpopulations, said David Atkins, director of the Department of Veterans Affairs Health Services Research and De- velopment Service. For example, while veterans often have physically de- manding jobs that increase the incidence of chronic pain, they may also be unable to take the time off for multiple sessions of acupuncture, chiroprac- tic, or cognitive behavior therapy (CBT). Thorn noted that low-income populations are often excluded from clinical trials for various reasons, including low literacy. Given that the conclusions drawn from randomized clinical trials with middle-income participants may not generalize to the broader population, Thorn argued for research that focuses on modifying treatments for disadvantaged indi- viduals. For example, she and her colleagues have adapted CBT and self- management treatments by adapting the workbooks and other tools for people with low literacy. In a randomized clinical trial of this literacy- adapted and simplified group CBT approach compared with group pain education or usual care, they showed that after treatment, participants in the modified CBT and group pain education arms had lower pain intensity scores and improved function compared with the usual care arm (Thorn et al., 2018). Interestingly, she said, individuals with the lowest literacy lev- els and lowest cognitive function received the most benefit from adapted CBT. Anthony Delitto added that modifications of some nonpharmacolog- PREPUBLICATION COPY: UNCORRECTED PROOFS

14 NONPHARMACOLOGICAL APPROACHES TO PAIN MANAGEMENT ical approaches such as exercise and yoga are also needed for certain sub- populations (e.g., older adults) who may have limited mobility, flexibility, strength, or stamina. PREPUBLICATION COPY: UNCORRECTED PROOFS

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Pain is a leading cause of disability globally. The dramatic increase in opioid prescriptions within the past decade in the United States has contributed to the opioid epidemic the country currently faces, magnifying the need for longer term solutions to treat pain. The substantial burden of pain and the ongoing opioid crisis have attracted increased attention in medical and public policy communities, resulting in a revolution in thinking about how pain is managed. This new thinking acknowledges the complexity and biopsychosocial nature of the pain experience and the need for multifaceted pain management approaches with both pharmacological and nonpharmacological therapies.

The magnitude and urgency of the twin problems of chronic pain and opioid addiction, combined with the changing landscape of pain management, prompted the National Academies of Sciences, Engineering, and Medicine to convene a workshop on December 4–5, 2018, in Washington, DC. The workshop brought together a diverse group of stakeholders to discuss the current status of nonpharmacological approaches to pain management, gaps, and future directions. This publication summarizes the presentations and discussions from the workshop.

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