January 15, 2020 11:08 am Michael Devitt – Chronic pain can cause ordinary people to take extraordinary measures to try to make the pain go away, including engaging in potentially harmful behaviors such as alcohol and drug misuse.
Although prescription medications such as opioids are often used to manage chronic pain, family physicians also have a wide range of nonpharmacologic treatment modalities at their disposal. These include simple, noninvasive methods such as massage and heat, as well as more complex therapies such as acupuncture and chiropractic manipulation.
Previous research has suggested that using nonpharmacologic therapies to manage chronic pain may be effective not only in decreasing pain and improving function but also in reducing longer-term adverse effects such as substance use disorders and suicide attempts. A recent study of active-duty U.S. Army service members has provided strong evidence to support this claim.
The study, published online Oct. 28 in the Journal of General Internal Medicine, found that individuals who received nonpharmacologic therapies in the Department of Defense's Military Health System were considerably less likely to experience adverse outcomes after they transitioned to the Veterans Health Administration within the Department of Veterans Affairs.
"Chronic pain is associated with adverse outcomes such as substance use and suicidal thoughts and behavior," said Esther Meerwijk, Ph.D., M.S.N., a statistician at the VA Palo Alto Health Care System in California and the study's lead author, in a news release. "It made sense that if nondrug treatments are good at managing pain, their effect would go beyond only pain relief. However, I was surprised that the results of our analyses held, despite our attempts to prove them wrong."
Meerwijk's research, part of an ongoing project called the Substance Use and Psychological Injury Combat Study, used a longitudinal cohort design. Her team reviewed the health records of more than 275,000 active-duty service members who reported chronic pain after a deployment to Iraq or Afghanistan that ended between Oct. 1, 2007, and Sept. 30, 2014.
First, the researchers reviewed diagnostic and procedural codes in each service member's MHS record to determine whether they had received any of 13 nonpharmacologic therapies after their deployment. Those therapies were acupuncture or dry needling, biofeedback, chiropractic care, cold laser therapy, exercise therapy, lumbar supports, massage, osteopathic spinal manipulation, other physical therapy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography.
The researchers then analyzed the ICD diagnosis codes of service members after they enrolled in the VHA through Sept. 30, 2018, to identify long-term adverse outcomes. Outcomes of interest included diagnoses of alcohol and/or drug disorders; poisoning with opioids, related narcotics, barbiturates or sedatives; suicidal ideation; and self-inflicted injuries, including suicide attempts.
Using propensity score weighting to analyze similarities and differences between service members with chronic pain who received nonpharmacologic therapies and those who did not, the authors determined that service members with chronic pain who received these therapies while in the MHS were at significantly lower risk of experiencing long-term adverse outcomes than those who did not.
Specifically, service members who received nonpharmacologic therapies were
The researchers acknowledged several limitations in their research. For example, although most nonpharmacologic therapies were provided after service members were diagnosed with chronic pain, the authors could not determine whether those nonpharmacologic therapies were used specifically to treat that pain.
In the news release, Meerwijk also explained that her team did not study the effects of individual nonpharmacologic therapies.
"We treated them as one," she said. "Most likely, only some of the therapies that we included are responsible for the effect that we reported, whereas others may have had no effect at all, assuming there's no other variable that explains our findings."
Despite these limits, the authors expressed confidence in their research methods and findings.
"Our results suggest that (nonpharmacologic therapies) provided to active-duty service members with chronic pain may reduce their odds of long-term adverse outcomes," they concluded in the study. "Given known associations of these adverse outcomes with morbidity and mortality, providing (nonpharmacologic therapies) to service members with chronic pain could potentially save lives."
Former chair of the AAFP Commission on Health of the Public and Science David O'Gurek, M.D., who practices in Philadelphia, told AAFP News that although family physicians should not be surprised by the findings, more work needs to be done to clarify which nonpharmacologic therapies work -- and which don't.
"The study certainly highlights that there is value and a role for nonpharmacologic therapies for the treatment of pain; however, it doesn't necessarily provide clear guidance on which therapies work best for a specific condition," O'Gurek said. "While clustering therapies together demonstrated effect, further research into individual strategies for specified conditions is needed to ensure that evidence-based practices are provided to patients at the individual level."
Although external factors such as insurance coverage may lessen the generalizability of the findings to practicing FPs and their patients, O'Gurek noted that the study itself could have some long-term value.
"While guidelines and recommendations have suggested that nonpharmacologic strategies be utilized for treatment, these recommendations highlight significant inequities in care, as many insurance plans do not cover (them), and out-of-pocket costs associated with some of these nonpharmacologic strategies limit access," he said. "Studies such as this can draw greater attention to these strategies and direct changes in policy around coverage for services that can benefit populations.
"This does present opportunities for family physician researchers to investigate further data around these options that could force policy and coverage changes to allow for access and care implementation," O'Gurek added.
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