Podcast: Non-medication Treatments for Pain

I'm joined by Dr. Lindsay Botsford, who is the market medical director for Iora Health in Houston, a clinical associate professor of the Department of Clinical Science at the University of Houston College of Medicine. Today we are speaking about non-medication treatments for pain.

Sure. Good morning, Dr. Moy. So let me start a little bit by framing pain. We think of it as acute and chronic, if we think about two big categories. And acute pain tends to be some type of specific response to an injury. The duration can be anywhere from five days to three months. And a single broken bone can be different than someone who has a devastating car accident or something like that. We think of chronic pain as any pain that lasts beyond the expected duration of healing. So there's estimates now that up to 50% of Americans live with chronic pain in their lifetime, the most common of which is chronic low back pain. But older adults, including nursing home residents, tend to have a higher incident of chronic persistent pain. And neurobiology tells us that chronic pain is not just a persistent injury, but it's overactivation of the nervous system in response to that pain and leads to this hyperalgesia. This is a lot of the reason why back surgeries and knee arthroscopies fail in the first place. Our bodies tell us this pain is real long after that initial injury happens. Older adults, in particular, are different in their response to pain. And often, that transition from acute to chronic pain happens differently. They will sometimes be reluctant to confirm the presence of pain, which leads to different ways we need to treat older adults. But the treatment of pain almost always starts in a primary care physician's office. In Medicare, the incidence of chronic pain is just increasing. So over the last two years, one in three Medicare beneficiaries were treated with an opioid at some point, which is a huge number. And you can imagine, as a result of that increased exposure, the rates of opioid use disorder are increasing. And the incidence of ER visits, where a patient has a complication related to those opioids, is also increasing, some estimates by as much as 75% in the last 10 years.

Wow. That's a lot of ER visits. Now by overdose, let's talk about that just a moment. We're talking mostly about people who are 65 or older.
Yeah. So I think that's a fair start. So a lot of the statistics looked at pain under age 50. So 50 to 64. But when we say older adults, over 65 is generall1y what we're talking about, specifically around Medicare patients.

Do you have any information about -- there's any segmentation in that growing age demographic? So from 65 to 75, 75 to 85, above 85. Any thoughts about how many patients experience pain and where they might be? What might be the cause of that pain?

Yeah. The data doesn't break it down quite that specific yet in terms of that. But we do know that biology of aging changes the way that older adults can perceive pain, as well as how they respond to the medications we sometimes use to treat pain. So it is certainly a continuum. There is not a magic thing that becomes uniform when an older adult reaches 65. And we certainly can think that some of the side effects are magnified as we get into our older adults above age 80.
 I'll just go off our topic list, just a little bit here, because it's been in the news, and I'm a psychiatrist. There's been a lot of discussion recently about the impact of loneliness on older Americans. Does that have any impact on prescribing of opioids? Or is that just some myth out there? Is that just a, you know, a strawman out there to say, "Oh, it's all due to loneliness. Everyone should get a puppy."?

You know, we think social isolation is a contributor to worse health outcomes overall. And that includes around perceptions of chronic pain as well as mental health conditions. So we know that older adults have more complex health conditions. They also have more nonfatal injuries and falls that may lead to pain. That pain they experience is often a symptom of other conditions combined. So when you lay around social factors like social isolation, lack of social support, it can certainly lead to worse outcomes and worse perception of pain. We know that our dual eligible Medicare beneficiaries have worse social factors that contribute to their chronic pain, leads to higher complication rates, higher uses of substances for longer periods of time than intended. So it definitely is relevant.

Well, that's great. Dr. Botsford, you've chosen to focus your practice on older adults, specifically Medicare beneficiaries at this time. So I'm just going to put that out there. So you really know this patient population, which you've also identified, maybe a great future topic for us to discuss, the social determinates of health and its impact on our healthcare quality and access and cost. Let's move on at this point. So we've had a lot of discussion lately among physicians about practice guidelines  and evidence-based care. Those seem to be some really key words. As a member of the National Quality Form, that's definitely one of the things that we look at or that you look at, looking at measures and how those measures come about. I sit on the PCPI Mental Health Technical Expert Panel. So we help develop and refine those guidelines. What are your thoughts about where guidelines come from and whose guideline can you trust?

Yeah, that's a good question. So doctors prescribed a lot of opioids in the past, in part because there was no system to provide this whole person care to vulnerable populations and little incentives from payers or other providers to implement one. So it's been pretty recently that there has been attention provided to the issue of effective treatment of chronic pain. When you couple that with the increase in opioid use disorder, there was a big void in people who were weighing in on what actually works for chronic pain. So in 2016, the Center for Disease Control and Prevention, the CDC, issued the first national guideline in the US regarding opioid prescribing for pain. So I think one of the highlights is it included the recommendation that patients treated for acute pain should receive opioids for no longer than seven days. And that triggered states like Texas to implement laws requiring providers to not exceed a certain threshold when providing initial opioid supplies. It included a lot of other guidelines that helped inform prescribers on safe ways to handle chronic pain. So it was a great start because it was the first time we had a comprehensive set of guidelines. And overall, there's pretty broad consensus that they're good medicine. I think the challenge with guidelines become when the guidelines get translated into laws or into policy. So when we think about guidelines, they're recommended to be a best practice at a population level. And we always need to think about patients as individuals and as people too whenever we're applying guidelines. For example, one of the big studies on which the guideline was based, it looked at incidence rates of long-term use. And it showed that we know that if patients take an opioid for more than five to ten days, their rates of long-term use are higher. But it didn't really clarify whether that long-term use meant dependence or addiction or other problems due to that short-term exposure. So I think that's just an example of sometimes taking the science and writing a guideline that's very well intentioned, but it doesn't always apply to your individual patient. And I think that's the art of medicine where we have to step in and use those guidelines as a framework for taking care of our patients.

Oh, sure. In psychiatry, we've had lots of really good guidelines that I believe have advanced care significantly and treatment of severe and persistent mental illnesses such as schizophrenia, bipolar disorder and major depression. But within those guidelines, there's always the exception because you always have to look at the patient that's sitting across from you to know what they need or that they don't need. It's not -- patients aren't widgets. This is not an assembly line robotic checklist type of care that we're talking about or advocating for. But it's really to help provide a roadmap. Should patients ask their prescribers about which guidelines they're using or research them on the internet, the infamous Dr. Google? I mean, they're all out there. And everyone has got an opinion about this.

That's -- I would say we always encourage our patients to do their research ahead of time and come with questions but be open to the conversation. So since the CDC guidelines have come out, various -- especially organizations have commented, created their own guidelines and framework. And this includes people like the American College of Physicians, the American Academy of Pain Medicine, the American Society of Anesthesiology to name a few. So there's differences on how to implement to a specific patient, but there's pretty broad consensus on the principles at the population level. So if you were to look at any of those sets of guidelines, you'd see some pretty common themes in there. Themes like pain as a comprehensive feeling that requires a multidisciplinary approach and that opioids should not be first line for that. And so I think that message is great for patients to get. We always are wary when we come in with a patient that's asking for a very specific intervention. So as long as we're open to the conversation, I think it's great to look at things online.

Okay. That's great. So hopefully, our patients will be informed patients. We can have discussions with them about their overall treatment plan, because it's not really about I have pain today, and I want you to write me a prescription. But it's what's causing that pain? What do we do to prevent it in the long run? But also -- and also, what we do to make you more comfortable. You know, I can't think of anything that's more painful than an attack of gout. Gout is not just an acute illness. It's a long-term proposition. But there are a number of strategies for it. I don't know that we have all the answers for it. But it's definitely something that's manageable without the -- hopefully, without the use of opioids because you don't want to get to that point. I can tell you that from personal experience.
I think that's right. I think anything that gets the message that when a patient comes into their doctor, they should be thinking about how is the doctor going to treat my pain and not what medication is the doctor going to give me. And so any discussion around that is a good place to start.

Well, since the CDC has weighed in, have we seen more of a convergence on the practice guideline for treatment of pain, meaning that there are fewer differences among specialties or organizations that advocate for treatment of pain?

Yeah, I think that's right. You'll see some variation in when interventions are recommended and strengths of evidence of different modalities versus others. But we're starting to see things converge on this idea that the treatment of pain needs to be multidisciplinary in approach. And medications can have a role, but they're usually not first line, opioids or otherwise. And I think you'll see that pretty consistently through all the different guidelines you'll read.
Okay. Well, I want to ask you how you treat and manage pain in your patients. You've got a Medicare population today.

That's right.They have many chronic illnesses, I'm sure, from orthopedic injuries to neurologic diseases to other types of autoimmune diseases and who knows what else. So how would you view this -- your treatment of pain in relation to the guidelines? Walk us through how you approach a patient.
Yeah, sure. So in older adults, I guess I may start by sharing that we always treat them as an older adult first and a patient with pain second. So the idea is that especially in older patients, we know pain is more than just a sensory event. And comprehensive geriatric pain assessment is important for older adults to get at the sensory, the emotional, the functional, the social supports that really go into figuring out how we can help our patients deal with pain.

That sounds like a lot of talking.

It is. I think that would be a great thing to prepare both physicians and patients for. This is not a ten-minute visit, and this is not just going to end with a prescription for a medication. It's a conversation about how we can comprehensively treat pain.
So in a way, to set the expectation for our patients that it's more than just a blood test or x-ray, that we're really going to have to talk to them, get to know them and understand everything about their life.

That's right. And I think sometimes, it can appear frustrating because it seems like we're distracting the patient from getting them the relief they want. But an example of one approach to the evaluation of pain is in older adults, it's helpful to do a mobility assessment before we think about prescribing medications. Sometimes, we will even recommend prehab or physical therapy for patients even if we are thinking about starting something like an opioid because we know that opioids can increase the fall risk and lead to problems down the line. So there's lots of things that we think about together with that. To your comment about x-rays, you know, diagnostic imaging tends to be pretty overused in this population. Degenerative pathology is almost always seen on imaging, and it doesn't really correlate very well with the level of the pain. So to effectively treat the pain, unless there's unusual symptoms, x-rays and MRIs often don't even need to be a part of the evaluation.
Wow, because I think a lot of patients expect that, that that's going to give the definitive diagnosis. Do I have a fracture? Do I have joint erosion? I don't -- that's a big change, I think, for most people to say, "We're going to talk about this, and I'll do a physical exam. And then we'll talk about all sorts of things that you might want to do or need to do before you get to that point of getting a prescription."

That's right. I mean, there's a role for imaging, certainly in acute pain, if we're worried you've broken a bone. There's a role for an x-ray. But when patients have had pain for that chronic condition, more than three months, let's just say, assuming their exam doesn't show any unusual things, the image is rarely going to lead to something that's going to change my plan right away anyway. There's lots of things we can try, assuming that exam is within normal limit, before we need to think about going there.
Okay. Okay. Well, that's fair enough. Who wants to make another trip to the x-ray department and schedule that? And it is a little bit of a change of expectation. I don't watch many medical TV shows, so I can't really comment on it. But I would just expect that they do a lot of imaging on those shows.
They probably do. TV is not always like real life, in a good way. But, you know, we do delineate a bit between acute pain and chronic pain. So perhaps it would make the TV shows that are surgical. And hospital-based colleagues have actually done all sorts of innovative strategies to avoid opioids even in acute settings. Things like extended nerve blocks post procedure, using IV Tylenol or other ways to control pain that don't involve using opioids even for what on TV might look like a pretty dramatic injury. Dr. Botsford, thank you for your time today and all of your great knowledge. Thanks for the time. Bye bye.

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