Case-Based Review

Nonpharmacologic Treatment of Chronic Pain—A Critical Domains Approach

Journal of Clinical Outcomes Management. 2016 February;23(2)

Author(s):

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From the Department of Anesthesiology, University of Michigan, Ann Arbor, MI.

Abstract

Objective: To provide an overview of the critical treatment domains for patients with chronic pain and describe nonpharmacologic strategies by which these domains can be addressed.
Methods: A literature review was conducted to evaluate the evidence underlying commonly used nonpharmacologic strategies for the treatment of chronic pain, with a focus on interventions that require patient engagement.
Results: Nonpharmacologic interventions that actively engage the patient in pain management, such as exercise, behavioral activation, sleep hygiene, and stress management, are relatively easy to implement and do not necessarily require the expertise of mental health professionals. Nonpharmacologic strategies can directly address pain and also address secondary complications, and thus serve to enhance treatment outcomes.
Conclusion: The critical domains approach can be used to organize a comprehensive nonpharmacologic approach to treating widespread chronic pain.

According to the Institute of Medicine (IOM), chronic pain affects more Americans than coronary heart disease, diabetes, and cancer combined at an estimated cost of $635 billion per year [1]. While it has been demonstrated that we have reasonably good ability to reduce acute pain, providing pharmacologic treatment with even modest effects when addressing chronic pain remains challenging [1]. The ability to treat one form of pain successfully but not the other stems from the fact that chronic pain is not a simple extension of acute pain [2,3]; rather, the mechanisms differ and so must the treatments. The IOM report called for a cultural transformation in how pain is understood, assessed, and treated. In response, the National Pain Strategy [4] was developed. It was recommended that efficacious self-management strategies be used for individuals with chronic pain; such strategies are largely nonpharmacologic [4].

This article presents an approach to addressing chronic pain using nonpharmacologic strategies. While a number of nonpharmacologic treatments involve patients as passive recipients (eg, massage, acupuncture, balneotherapy or spa treatments), most require the patient to be engaged, eg, to exert physical energy, learn a new skill, and/or change a behavior. The approach presented here is organized around addressing critical domains, including the need to increase activity, deal with psychiatric comorbidities, address sleep problems, and tackle stress. The strategies suggested will be those that have the best evidence base and are predominantly ones that can be deployed by physicians and other health care professionals who do not necessarily have specialized training in behavioral health. A case is presented to illustrate this approach.

Case Presentation

Lisa is a 42-year-old Caucasian woman with a 2-year history of chronic low back pain presenting to a primary care clinic. She reported that the back pain began when she was working as an office manager in a busy dental clinic. The onset was sudden, occurring when she lifted a heavy box of copier paper using a “leaning and twisting motion.” The pain is described as constant (rated as 5 out of 10) and she experiences periods of more intense pain or “flares” (rated as 9 out of 10); Lisa noted that “10 is reserved for childbirth.” The flares seem to coincide with periods of stress and can result in up to 2 days of immobility, causing her to miss work at the dental office.