Develop a Collaborative Pain Management Strategy

JANUARY 21, 2019
Sarah B. Sanchez, PharmD Candidate, and Deepali Dixit, PharmD, BCPS, BCCCP, FCCM
Pain is one of the most frequent reasons that patients seek medical care.

However, the complexity of pain can make strategizing for treatment difficult. It takes more than 1 approach and specialty to effectively manage pain. Beyond the physical, pain causes emotional, mental, and social burdens that can reduce quality of life.1 Practitioners must become skilled in collaborative and strategic pain management across the health care system.

A comprehensive approach to pain management requires that the patient with pain have an active role in determining the balance of biofeedback, counseling, medication, nutrition, physical therapy, and other adjunct nonpharmacologic treatments required to maintain a functional lifestyle and quality of life. Patients with persistent pain should be well informed about the modalities of pain management, and they should have a regimen specific to them and their pain. Education allows patients to set realistic goals and be skillful in managing their pain. A multidisciplinary team of occupational therapists, pharmacists, physicians, physical therapists, and psychologists can provide additional support for quality treatment.

A collaborative approach incorporates active interventions (those that require patients to exert energy) and passive interventions (those that do not require activity by the patient). Some active interventions are management of medication regimens, deep breathing, meditation, self-distraction, tai chi, and yoga. Many active interventions are self-directed and do not require professional health care supervision after initial instruction.2 Passive interventions include acupuncture, injections, massage, medications, and surgery.

ALTERNATIVE, COMPLEMENTARY, AND INTEGRATIVE MEDICINE
Alternative and complementary medicine include nonmainstream modalities, such as chiropractic medicine, but differ in that complementary medicine also includes mainstream modalities, such as medications. Integrative medicine requires the coordination of complementary medicine with a patient-centered approach that addresses the emotional, functional, physical, social, and spiritual aspects of the patient’s life.3

The jury is out on the efficacy of acupuncture, massage, relaxation, and other complementary therapies. Although benefits have been seen with these approaches in disease states such as back and neck pain, fibromyalgia, migraine, and osteoarthritis, many studies are negated by conflicting data,4 and some are simply anecdotal. Yet, these approaches are important because strategies should be individualized. Patients must help determine what interventions work.

CONVENTIONAL MEDICINE AND THE ROLE OF HEALTH CARE PROVIDERS
Time spent with patients is an invaluable part of pain management. Motivational interviewing and shared decision making improve a patient’s ability to take control over the pain. Demonstration of compassion and knowledge are crucial to establishing a long-term relationship in which frequent follow-up is encouraged.

Although therapeutic emphasis is shifting from analgesic medications to an integrative approach, pharmacists and prescribers still have critical roles as educators and providers of the medications in the toolkit. Consideration of overall medical history, pain type, and severity is important when determining which medications should be a part of the pain management strategy. A patient with pain in 1 or 2 areas is likely suffering nociceptive pain, whereas a patient with a dermatomal region or stocking-glove distribution likely has neuropathic pain. Multifocal pain is often chronic and extends beyond physical sensations to alterations in energy, memory, mood, and sleep.5 When selecting the best agent, it is crucial to work with the patient to consider the role of analgesics in the management strategy. Consistent follow-up allows providers to determine not only efficacy and safety of medications but also whether they are bearing too little or too much weight in a patient’s overall pain management strategy.

Some common pain states include chronic low back pain, complex regional pain syndrome, diabetic neuropathy, fibromyalgia, myofascial pain syndrome, postherpetic neuralgia, and radicular pain. Acetaminophen, monoamine reuptake inhibitors, local anesthetics, membrane stabilizers, muscle relaxants, nonsteroidal anti-inflammatory drugs, opioids, and topical capsaicin have varying levels of success in these conditions.6 With the continuing opioid epidemic, American Society of Interventional Pain Physicians guidelines recommend a high level of involvement on the part of the provider in identifying true candidates for opioid therapy and monitoring efficacy and safety.7

Pharmacologic pain management via a collaborative strategy alleviates symptomatic pain. Patients should be encouraged to report pain to their providers.8 After initial self-care therapies, prescription management has a role that should be in addition to appropriate complementary methods, such as spinal manipulation in back pain.9 Counseling, follow-up, and reevaluation of strategy efficacy are important in all cases but should be increased in patients with severe chronic pain who require strong analgesics with increased addiction potential.

Pharmacists can have a huge impact in guiding patient decisions and reinforcing follow-up. When a patient presents with symptomatic pain from a chronic condition, ask questions regarding aggravating and relieving factors, determine what methods are being used, and suggest the right medication for the type of pain. Providers should be skillful in working with patients to create a collaborative pain management strategy that balances complementary medicine, pharmacologic therapies, and self-care. Empowered patients with chronic pain conditions can live quality lives through frequent follow-up, modifications to suit their individual conditions, and well-rounded care.
 
Sarah B. Sanchez is a PharmD candidate at the Ernest Mario School of Pharmacy at Rutgers, the State University of New Jersey, in Piscataway.

Deepali Dixit, PharmD, BCPS, BCCCP, FCCM, is a clinical associate professor at the Ernest Mario School of Pharmacy and a clinical pharmacy specialist, critical care, at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.


REFERENCES
  1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. doi: 10.15585/mmwr.mm6736a2.
  2. Feinberg S. ACPA resource guide to chronic pain management: an integrated guide to medical, interventional, behavioral, pharmacologic and rehabilitation therapies. American Chronic Pain Association website. theacpa.org/wp-content/uploads/2018/05/ACPA_Resource_Guide_2018-Final_ Feb.pdf. Published 2018. Accessed December 13, 2018.
  3. US Department of Health and Human Services. Complementary, alternative, or integrative health: what’s in a name? National Center for Complementary and Integrative Health website. nccih.nih.gov/health/integrative-health#hed1. Updated July 2018. Accessed December 13, 2018.
  4. Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidencebased evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc. 2016;91(9):1292-1306. doi: 10.1016/j.mayocp.2016.06.007.
  5. Schneiderhan J, Clauw D, Schwenk TL. Primary care of patients with chronic pain. JAMA. 2017;317(23):2367-2368. doi: 10.1001/jama.2017.5787.
  6. Nicol AL, Hurley RW, Benzon HT. Alternatives to opioids in the pharmacologic management of chronic pain syndromes: a narrative review of randomized, controlled, and blinded clinical trials. Anesth Analg. 2017;125(5):1682-1703. doi: 10.1213/ANE.0000000000002426.
  7. Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2017;20(2S):S3-S92.
  8. Brensilver M, Tariq S, Shoptaw S. Optimizing pain management through collaborations with behavioral and addiction medicine in primary care. Prim Care. 2012;39(4):661-669. doi: 10.1016/j.pop.2012.08.007.
  9. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.


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