Specifically, non-opioids are often preferred for the management of subacute and chronic pain because of their safety profiles.
In 2019, a National Health Interview Survey (NHIS) showed that a significant number of patients were living with chronic pain, which is considered to be pain lasting longer than 3 months, or high impact pain, which is pain that is affecting a patient's daily activities on most days of the week within the past 3 months, according to Emily E. Leppien, PharmD, BCPS, BCPP, during a presentation at the APhA 2023 Annual Meeting & Exposition. Leppien explained further that chronic pain should be treated as its own disease state just like other conditions would be, such as diabetes, asthma, or hypertension.
“Most recently, the CDC updated their guideline recommendations in November of 2022, and I still think it's very interesting that they call the guideline the CDC Guideline for Prescribing Opioids for Chronic Pain, despite the fact that their first 2 recommendations are to use alternative therapies before moving to opioid therapy,” Leppien said during the presentation. “When we're looking at a patient with chronic pain, non-opioid therapies are as effective as opioid therapies in the reduction of both acute, subacute, and chronic pain.”
Specifically, non-opioids are often preferred for subacute and chronic pain due to their safety profiles, according to Leppien. When compared to traditional opioid therapy, non-opioids can also be just as effective.
“When we're thinking about a patient with chronic pain, and we're trying to identify a pain management strategy, the goal is to use multimodal multidisciplinary interventions,” Leppien said. “Opioids should not be our default pain medication. We know that opioids are effective for pain, but they do come with significant risks, especially when used long term [such as for] chronic pain.
Further, non-pharmacologic therapies and non-opioid pharmacologic therapies are important to include in a multimodal, multidisciplinary approach. For many disease states, such as for diabetes or hypertension, non-pharmacologic interventions are commonly recommended. However, these same types of recommendations can pose challenges for the management of chronic pain because they are not quick, according to Leppien.
“We're not going to solve a problem overnight with a non-pharmacologic intervention or non-opioid medication, and that can be bothersome to the patient,” Leppien said. “But ultimately, by maximizing our non-opioid alternative therapies, we can either prolong the need for opioid use or decrease the amount of opioid a patient may need when it comes to that point.”
Based on steps of the WHO Analgesic Ladder, many providers follow the recommendation that after a patient fails a non-opioid therapy, they are then given an opioid therapy. However, this ladder for chronic pain treatment is following out of favor among providers due to its highly regimented structure. Further, there are alternative options available that can be prescribed after a patient is unsuccessful with their first non-opioid therapy instead of immediately moving to opioids after the first failed non-opioid, according to Leppien.
“It sometimes takes a little bit of finesse to identify which medication or which non-pharmacologic strategy can be effective for a patient, and we should do all that before we move to an opioid. As the pain resolves, then we would continue tapering the opioid, but that's a discussion for a different day,” Leppien said.
In the 2019 NHIS study that investigated the percentage of patients who have chronic or high impact pain, investigators also looked at the non-pharmacologic treatment strategies these patients were using, according to Leppien. The results showed that a majority of patients who were using some sort of non-pharmacologic intervention were participating in physical therapy. Additionally, below physical therapy in popularity was massage therapy.
“Then we see meditation or other sorts of relaxation techniques. But talk therapies such as psychoeducation or cognitive behavioral therapy were actually reported to be quite low [in participation], although there's a significant evidence supporting its use,” Leppien said.
A different study from 2012 also looked at the percentage of patients who were using complementary health or alternative treatment strategies for the management of chronic pain, according to Leppien. The results of this earlier study showed that most patients who were using some sort of complementary alternative medicine were primarily using it to treat back pain, with neck pain being the second most common, and anxiety and depression at the bottom in terms of the percentage of patients.
“This is quite interesting because a lot of patients with chronic conditions also have comorbid psychiatric disturbances or mood disturbances,” Leppien said. “We see anxiety and depression often in pain, which is why you may see deep breathing or relaxation techniques as a common therapy because not only is it shown to be helpful in pain management, but it also has evidence in treating mood disturbances.”
Leppien explained that when making decisions about the appropriate regimen or strategy for a patient with chronic pain, the treatment should reflect the type of pain the patient has, which can often be dependent on their description rather than the results from imaging. For example, although a herniated disc under compression may be visible on imaging, there may not necessarily be a physiologic reason or a pinpoint spot on the imaging that shows why the patient is experiencing pain.
“So a lot of times we need to take the patient's objective report and use that to identify the pain that the patient might be having when we're trying to come up with our treatment strategy,” Leppien said. “Patients who may describe their pain as radiating, burning, or electrical sensations most commonly are referring to a neuropathic type of pain, and how we treat a neuropathic type of pain is a little bit different than how we would treat inflammatory pain. So that's the first piece is kind of taking into consideration what your patient is explaining to you and the type of pain they have.”
Leppien noted that the second piece to consider is associated symptoms, which can include depression, anxiety, insomnia, or some other mood disturbance—this can be an important piece of helping the patient make their pain better. Frequently, a mood disturbance can exacerbate pain, and pain can exacerbate a mood disturbance.
“It's this vicious cycle or snowball effect of one condition worsening the other,” Leppien said. “So that's something to take into consideration when we're picking our pain management strategy.”
Leppien EE. “All In” on Pain Management with Alternative Therapy. Presented at: APhA 2023 Annual Meeting & Exposition in Phoenix, AZ; March 25, 2023.