The Role of Nonpharmacological Approaches to Pain Management Proceedings of a Workshop (2019) / Chapter Skim
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3 Effectiveness, Safety, and Cost-Effectiveness of Nonpharmacological and Nonsurgical Therapies for Chronic Pain
3 Effectiveness, Safety, and Cost-Effectiveness of Nonpharmacological and Nonsurgical Therapies for Chronic Pain
Pages 15-24
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From page 15... ...
Over an approximate 10-year period from 2000 to 2010, there was an approximate four-fold increase in opioid prescribing, despite limited short-term benefits, lack of data on long-term benefits, and clear evidence of serious harms, said Roger Chou, professor of medicine, medical informatics, and clinical epidemiology at the Oregon Health & Science University School of Medicine. Other pharmacological treatments for pain are also associated with similarly modest benefits, said Chou, without the risk of overdose or opioid use disorder.
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From page 16... ...
The study stratified patients according to psychosocial factors that influence their risk of developing chronic low back pain, and then used a stepped-care approach to deliver more intensive cognitive behavioral therapy (CBT) informed physiotherapy aimed at reducing disability and improving function to those at higher risk (Hill et al., 2011)
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From page 17... ...
He noted several challenges associated with collecting these data, including the inability to mask treatments, variability in techniques and intensity of treatments, differences among providers, the small magnitude and duration of effects, interindividual variability including the presence of psychological comorbidities, maladaptive coping behaviors, fear avoidance, catastrophizing, sensitization of the central nervous system, and concomitant use of opioids. Furthermore, data on functional effects have been limited.
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From page 18... ...
The TABLE 3-1 Effectiveness and Strength of Evidence of Nonpharmacological Treatments for Chronic Pain Versus Sham, No Treatment, or Usual Care as Described in the 2017 American College of Physicians Systematic Review on Low Back Pain Intervention Magnitude of Effect Strength of Evidence Acupuncture Moderate Low–moderate Exercise Small Moderate Interdisciplinary Moderate Low–moderate rehabilitation Massage No effect Low Psychological Small–moderate– Low–moderate interventions improved Spinal manipulation No effect–small Low Tai chi Moderate Low Yoga Small–moderate Low SOURCES: Presented by Roger Chou, December 4, 2018; derived from Qaseem et al., 2017.
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From page 19... ...
; Number of + Signs Indicate Strength of Evidence Intervention Function Function Function Pain Pain Pain Short-Term Intermediate- Long-Term Short-Term Intermediate- Long-Term Term Term Effect Size Effect Size Effect Size Effect Size Effect Size Effect Size SOE SOE SOE SOE SOE SOE slight none none slight moderate moderate Exercise + + + ++ + + Psychological Therapies: slight slight slight slight slight slight CBT primarily ++ ++ ++ ++ ++ ++ Physical insufficient Modalities: none evidence no evidence no evidence no evidence no evidence Ultrasound + Physical Modalities: slight none moderate none Low-Level no evidence no evidence + + + + Laser Therapy Manual Therapies: slight slight none slight Spinal no evidence no evidence + + + ++ Manipulation Manual Therapies: slight none slight none no evidence no evidence Massage ++ + ++ + Manual Therapies: none none no evidence no evidence no evidence no evidence Traction + + Mindfulness Practices: none none none slight slight none MBSR + + + ++ + + Mind-Body Practices: slight slight moderate moderate no evidence no evidence Yoga ++ + + ++ slight none none slight none slight Acupuncture + + + ++ + + Multidisciplinary slight slight none slight slight none Rehabilitation + + + ++ ++ + NOTE: CBT = cognitive behavioral therapy; MBSR = mindfulness-based stress reduction. SOURCES: Presented by Roger Chou, December 4, 2018; from Skelly et al., 2018.
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From page 20... ...
. Chou noted that for chronic low back pain, there was some evidence of persistent benefits from multidisciplinary rehabilitation, but limited benefits for other chronic pain conditions and little evidence to support the use of specific techniques, duration, intensity, or sequencing of therapies.1 Chou said little evidence showed whether the use of nonpharmacological therapies influenced opioid use and associated harms.
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From page 21... ...
Chou added that few studies report levels of adherence to a treatment protocol, which can be a significant complicating factor. To move forward and develop the necessary evidence, Veasley said a number of questions need to be addressed, including whether a stepped or adaptive approach is needed to understand the efficacy of combined therapies; whether there are core components across nonpharmacological interventions that account for efficacy that could be standardized across studies; which research models and study designs would provide the rigor needed to generate evidence in a timely manner; and how the field can evaluate the efficacy of many types of interventions across pain conditions.
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From page 22... ...
. They reviewed studies that evaluated costs compared with usual care from the perspective of a hospital, payer, employer, or society in general.
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From page 23... ...
At RAND, Herman and colleagues have been working on a model for chronic low back pain that incorporates actual patient data on health care costs, productivity costs, and health-related quality of life for four health states: no pain, low-impact chronic pain, moderate-impact chronic pain, and high-impact chronic pain. This model allowed the researchers to carve out data from patients with different pain states to show that costs in the high-impact chronic pain group are most affected by various treatments and to determine which treatments provide the most cost savings.
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From page 24... ...
Herman suggested additional research priorities to increase understanding of cost-effectiveness: • Include measures of cost in all studies of effectiveness; • Identify and target high-impact chronic pain to get the greatest impact; • Expand the use of economic modeling using available evidence to better understand the economic impact of treatments; and • Expand the use of simulations to enable the design of targeted trials.
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