Nursing – Evidence-Based Practice

Introduction

Chronic pain is a major problem associated with patient function impairment, decreased quality of life, and increased burden to society due to loss of productivity and increased utilization of health care leading to more costs. In the United States, the prevalence and costs associated with chronic pain were estimated to be around $560-635 billion every year by 2010. The prevalence of chronic pain varies, although, in 2012, statistics indicated that at least 126.1 million adults experienced pain over the last three months while 25.3 million adults reported having experienced chronic pain every day (Stanos et al., 2016). Consequently, although management of chronic pain has gained some increased attention and even recognized as a public health crisis, there remains wide variability in clinical practices regarding effective management. Currently, available and popular practices for chronic pain management include the use of pharmacological options such as NSAIDs, antidepressants, anticonvulsants, and opioids among others. Unfortunately, most of these pharmacological interventions are associated with several negative effects and harmful effects on patients. For instance, the use of opioids is associated with addiction, misuse, and overdose overshadowing effective pain management. Alternatives to pharmacological interventions include the use of non-pharmacological pain therapies. However, are non-pharmacological pain management therapies effective and can they be used alone to manage chronic pain?

PICOT Question

In adult care settings (P), how effective is the use of non-pharmacological pain management (I) compared to pharmacological pain management (C) in the relief of chronic pain (O)?

Findings from Sources of Evidence

Chronic pain is multifactorial affecting both the physical and psychological elements of an individual. Despite advances in health care, management of chronic pain remains a significant problem to health care. Drawing upon existing literature, management of chronic pain mainly involves the use of pharmacological interventions, although recently, health care providers have been considering the use of non-pharmacological interventions. However, non-pharmacological pain interventions are often underutilized, leaving pharmacotherapy as the most commonly utilized approach to chronic pain management. According to Stanos et al. (2016), some of the commonly used pharmacological approaches include NSAIDs and opioid analgesics. However, as Stanos et al. highlight, NSAIDs may have increased risk in older patients and lead to adverse events. In this case, NSAIDs should be administered using the lowest dosage and for the shortest time possible. On opioids, Stanos et al. highlighted that opioids may be medically appropriate and safe for select patients with chronic pain, especially when such pain cannot be managed with other methods. Nonetheless, several factors should be considered before using opioids in the management of chronic pain. For instance, emerging data suggest that extended use of opioids may be inappropriate to certain populations of patients. Besides, opioids are associated with several negative effects such as addiction, misuse, and some adverse events in certain patient populations. Subsequently, it is important to note that pain may not have only one type of pathophysiology. Sometimes, most patients have more than one type of pain pathophysiology and in this case, Stanos et al. recommends the use of both pharmacological and non-pharmacological therapies.

Ideally, the ultimate goal of chronic pain management is to optimize the use of non-pharmacological interventions. According to Stanos et al. (2016), non-pharmacological approaches should be integral in the management of chronic pain and include self-help, self-management education, physical and psychological therapies, and complementary and alternative medicines among others. However, although these non-pharmacological interventions achieve certain levels of pain relief in patients with chronic pain, they are not effective when used alone. Instead, Stanos et al. recommend a multidisciplinary and collaborative approach in managing chronic pain. Consequently, Pak, Micalos, Maria, and Lord (2015) sought to examine the effectiveness of non-pharmacological therapies (acupuncture, transcutaneous electric nerve stimulation, and physical therapies) in the management of chronic pain and found that these therapies were more effective in the management of acute pain. According to Pak et al., non-pharmacological therapies were effective in the management of chronic pain if combined with pharmacological therapies. In this case, the authors recommended that as a developing profession, paramedicine should investigate multiple pain relief modalities and consider complementary and alternative approaches to manage chronic pain and probably minimize the reliance on pharmacological approaches.

Tang, Tse, Leung, and Fotis (2019) conducted a systematic review that included articles from 2005 to February 2019 using PRISMA to guide the search process. The study sought to examine the effectiveness of non-pharmacological interventions in managing chronic pain in community-dwelling older adults. Results indicated that non-pharmacological interventions such as acupressure, qigong, Tai Chi, and hydrotherapy were effective in reducing pain intensity. However, there were concerns about ways to maximize the effects of pain management and maintain sustainability. Notably, the authors also failed to mention whether non-pharmacological therapies had the ability to manage chronic pain without combining with pharmacological interventions. In a different study by Thomas, Maslin, Legler, Springer, Asgerally, and Vadivelu (2016), the literature review evaluated articles from PubMed on various non-pharmacological chronic pain management approaches. Similar to the study by Stanos et al. (2016) that identified pain as a complex condition affecting the physical and psychological element of an individual, Thomas et al. opined that chronic pain should not be treated only using biomedical interventions due to the psychological component. Thomas et al. reviewed in-depth the effectiveness of acupuncture, natural and herbal supplements, whole-body cryotherapy, and smartphone technologies. Results indicated that these therapies appeared to be effective in the management of chronic pain. For instance, the use of natural and herbal supplements was found to be effective in providing chronic pain in patients. In particular, the use of lavender oil applied alongside acupressure was found to provide relief to patients with chronic low back pain. However, these patients also underwent additional interventions. Pharmacological methods and invasive procedures have the ability to reduce chronic pain symptoms but fail to relieve the emotional and cognitive elements of chronic pain. Consequently, the use of non-pharmacological therapies is effective in managing the psychological component of chronic pain, which means pharmacological agents are needed to manage the physical component of pain.

Relevance

Chronic pain management forms an integral element in the delivery of quality care in health care settings. The PICO question sought to determine whether non-pharmacological pain interventions were more effective compared to pharmacological interventions in the management of chronic pain. The purpose was to help decide whether non-pharmacological pain interventions can replace pharmacological interventions within the care settings. Results indicated that although non-pharmacological therapies are effective in managing chronic pain, they cannot be used alone. Chronic pain is multifactorial affecting the physical, psychological, and emotional elements of the human body. These therapies are effective in the management of the psychological and emotional elements of chronic pain. In this case, pharmacological interventions are needed to manage the physical element of chronic pain.

References

Stanos, S., Brodsky, M., Argoff, C., Clauw, D. J., D’Arcy, Y., Donevan, S., Gebke, K. B., … Watt, S. (2016). Rethinking chronic pain in a primary care setting. Postgraduate Medicine, 128(5), 502-15.

Tang, S. K., Tse, M. M. Y., Leung, S. F., & Fotis, T. (2019). The effectiveness, suitability, and sustainability of non-pharmacological methods of managing pain in community-dwelling older adults: a systematic review. Bmc Public Health, 19(1), 1-10. https://doi.org/10.1186/s12889-019-7831-9

Thomas, D. A., Maslin, B., Legler, A., Springer, E., Asgerally, A., & Vadivelu, N. (2016). Role of Alternative Therapies for Chronic Pain Syndromes. Current Pain and Headache Reports, 20(5), 1-7.

Pak, S. C., Micalos, P. S., Maria, S. J., & Lord, B. (January 01, 2015). Nonpharmacological interventions for pain management in paramedicine and the emergency setting: a review of the literature. Evidence-based Complementary and Alternative Medicine: Ecam, 2015. http://dx.doi.org/10.1155/2015/873039