Question: Evidence supports a positive impact in chronic pain for ALL BUT which of the following interventions?
1. Physical therapy
2. High dose opioid therapy
3. Cognitive behavioral therapy
4. Use of targeted therapy to address neuropathic pain
Discussion
Please note that you were asked to indicate which of the answers does NOT have good evidence of benefit
1. Incorrect because evidence supports that physical therapy can improve both pain and function in patients with chronic pain, particularly musculoskeletal pain.
2. Correct. There is no evidence that high dose opioids improve pain or function in patients with chronic pain syndromes. However, there is evidence that higher doses of opioids place people with chronic pain at risk of mortality and vehicular accident.
3. Incorrect. Cognitive behavioral therapy has an effect on mood and catastrophizing outcomes, and a small effect on pain and disability.
4. Incorrect. The use of medications that target neuropathic mechanisms can improve pain scores for patients with a neuropathic component to their chronic pain.
Further recommended reading : Pharmacologic management of Neuropathic Cancer Pain: a comprehensive review of the current literature. Pain Pract. 2012 Mar;12(3):219-51
Plan
OPTION 1
Increase the patient’s oxycontin to match her current prn hydromorphone use, continue hydromorphone at current dosing. Track pain scores as primary outcome.
OPTION 2
Identify that patient’s primary goal is to continue to be able to work. Initiate duloxetine with the agreed upon goal of maintaining adequate pain management while improving function. Track functional outcomes.
Discussion
Option 1 is selected.
In the management of acute cancer pain, increasing opioid dosing is likely to result in improved pain control. After transition to a chronic pain syndrome this strategy becomes less effective, and places a patient at greater risk.
Opioid dosing may be increased until dose limiting side effects (such as sedation or decreasing function) are noted without marked improvement in pain scores or function. At that point, the provider should recognize that this strategy is not providing benefit that outweighs the risk of opioid medication use, and pursue different strategies.
Option 2 is more appropriate given lack of evidence that opioids improve outcomes in chronic pain and that higher doses of opioids are associated with greater risk of death secondary to accidental overdose.
Strategies to address pain in this patient should include assisting the patient to identify functional goals that are important to her and supporting optimal coping strategies through cognitive behavior therapy, addressing physical impairments with physical therapy, and utilizing opioid pain medications as an adjunct to these measures to assist patient in achieving goals.
Role of Patient Engagement and Education
Patient engagement and education about chronic health issues such as pain management is an essential component of the patient’s care plan.
Self-management strategies have been shown to be effective in improving compliance and outcomes in chronic illness.
Self Management
- Use open ended questions to explore hoped for benefits and pain management goals
- Collaborate with patient to develop management goals that are relevant for them
- Use ask-tell-ask strategy to ensure communication related to medication use is effective
- Assist patient to develop problem solving strategies
Information Delivery
- Provide informational handout on chronic neuropathy
- Teach patient deep breathing relaxation strategy
- Tell patient to use medications only as directed
- Tell patient to return to clinic in 3 months for follow up check on pain
Commentary on Different Management Options
- Ms. Jackson responded well to initiation of fluoxetine 20 mg twice daily.
- She engaged with both cognitive behavioral therapy and physical therapy in the Supportive Care and Survivorship Clinic.
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After 1 month of therapy, she tolerated downward titration of her oxycontin to 30 mg twice daily. Fluoxetine dose was increased to 30 mg twice daily. 3 months later she initiated discontinuation of oxycontin.
- She continued as needed use of hydromorphone, and verbalized feeling excited by her success in discontinuing the oxycontin.
- She secured an administrative nursing review position and now does not work night shifts or spend as many hours on her feet. She feels confident in her ability to continue working and has initiated an exercise program.
Cognitive Behavioral Therapy (CBT)
- CBT can help patients reframe their thinking about their pain. Ms Jackson demonstrates catastrophizing (“it’s ruining my life”), and learning to recognize that pain is not ruining her life can help her cope with pain better.
- CBT can help patients develop better coping strategies for chronic pain, so that they can better manage pain with healthy strategies.
Involvement of Inter-Professional Team
Note that Ms. Jackson’s management strategy involved not only her physicians and nurses, but also a psychologist who helped to address both her negative thinking about pain and assisted her with developing healthy and effective coping strategies, as well as a physical therapist who assisted with addressing Ms. Jackson's scar tissue,range of motion, and confidence about her ability to exercise independently. In practice, inter-professional strategies are synergistic.
