Hello, and welcome to another episode of the TMF Quality Innovation Network’s podcast series on evidence-based pain management alternatives. I’m Dr. Clifford Moy, the behavioral health medical director at TMF Health Quality Institute, a leading non-profit health care consulting organization based in Austin, Texas.
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 side effects of opioid use and substance use disorders.
What about nonmedication treatments for pain? What's your experience with those? I've heard a lot of things from using cold therapy, hot therapy, yoga, massage, all sorts of stimulators, electrical stimulators. What's your experience with that?
Yeah. It sounds like you've heard lots of good things. So the treatment of chronic pain is almost always multimodality and multidisciplinary in treatment. So I would probably include activity as number 1, 2 and 3. So sometimes, we say to patients, "Motion is like lotion for your joints." So keeping moving helps that pain and helps your perception of pain. Patients often don't know what it means when we say, "Go exercise." But we can use patient-centered things like staying active or using a fitness tracker to track steps in a given day. Those can sometimes be more accessible than talking about exercise very broadly. In older adults, we often use activities such as paste activity -- the idea that you start small and then gradually increase day by day at a regular rate, as long as it doesn't feel too overwhelming. We do use physical therapy as well. This is great if patients really have been immobile for a long time and need some assistance to get started. And then physical therapy and physical activity, things like Tai Chi, yoga, they have pretty good evidence base for them for chronic pain as well. Now hot and cold therapy, very little harm from it, although you want to make sure that your heating pad or ice pack is not left on overnight. Some patients find this useful. There's evidence for both of them. So we say whatever feels good, go ahead and use it.
Well, wait a minute. Not whatever feels good. Right?
You have a good point.
It gets us into trouble sometimes.
Another strategy we will commonly use for the treatment of chronic pain is cognitive behavioral therapy. It's evidence based. It's well established. There is sometimes problem with access to psychologists but -- both in terms of weight and insurance coverage, but interesting research has been done on remote cognitive behavioral therapy and showing it to be noninferior to in-person cognitive behavioral therapy. So studies out of the VA that show that there's lots of different options and there's even smartphone apps that can help out with things like mindfulness and meditation. So the apps Calm and Headspace are available for free. And you can use those to help out to do mindfulness and other strategies around that.
So let me go back and just clarify a little about this research term that we talk -- use, noninferior. What it really means is just as good as.
That's a great point. Yeah. So that is definitely doctor speak for showing that, you know, options where you would speak with a cognitive behavioral therapist on the phone or via remote video feeds can be just as good as doing it in person. So really interesting for patients in rural areas, older adults that have transportation issues and would like to do this but in the comfort of their own home. That can be a way to help get them treatment as well.
Sure. Just a little note about cognitive behavioral therapy or CBT as it's widely known. There are different styles of CBT and I think what you're talking about as far as the effectiveness studies really relate to the very traditional, standardized types of CBT with a limited number of sessions. This is not, you know, unlimited, ongoing use of CBT style interventions. But it's really the rigorous use of 16 to 30-session CBT therapy. I think that's an important clarification because there are some -- I think there are some issues related to how we do that. And certainly, the use of remote or distance therapy is a really intriguing and upcoming process that we have a treatment that we have for patients. And just the ability to do things on app, pretty mind-blowing for me that you don't even need necessarily a person. It might be an AI bot out there that's helping you to respond to things. And really being self-directed in your CBT.
Yeah. I think the relationship with a mental health professional is hugely important. And when we have access to it, we will by all means use it. But sometimes, we have to think creatively. And I think that's just an example for ways where in situations where patients have barriers to seeking care, we can think outside the box and get them access to things that help.
In your practice, are you able to do warm handoffs?
So in my practice, I'm lucky to work in an integrated behavioral health setting. And so we have behavioral health specialists that work with us to do warm handoffs, to help engage patients in treatment, to help patients do some activation and ways to get motivated around some of this treatment for chronic pain. Not everyone has that, but I think it's hugely important if you don't have that in your practice to develop relationships with mental health professionals in your community, because involving them in the care of our patients with chronic pain can help your practice, as well as help the outcomes for the patient.
That's right. I think integrated practice is an up and coming practice style. And I think the warm handoff, being able to introduce your patient to a mental health professional really helps to decrease the barriers to follow through with that part of the treatment plan. Well, that's great. Any other thoughts about alternative treatments? What about CBD oil? That's really popular. I hear the ads for that all the time now.
Yeah. Unfortunately, there's not really any evidence that would support that. And our caution is we don't know the risks. Really, the challenge with all of the CB oil is we don't really know the percentage of active substances in them. In our older adults on multiple medications with complex conditions, it would be probably something that I would recommend avoiding until we know more. But certainly, an area where there can be research done.
There's a lot of market hype about it, but right now, the research, the evidence that supports the use of CBD oil in any condition really isn't there. It may be in the future. And we're not really sure what a pharmaceutical grade versus a retail grade of that particular product that's sold in so many places now. It's just incredible how it's exploded. But people must really be searching for answers if they're -- to me, if they're headed in that direction when we have so many other known effective treatments for any number of conditions, including pain.
They are. You know, for integrated treatments, we do have evidence that massage, spinal manipulation and acupuncture can play a role in addition to multidisciplinary rehab. So there are options out there for patients who want to avoid medications.
So we've really talked about how we assess patients, some ideas about treatment and alternatives to opioids. We've talked about the prescribing of opioids, trying to understand where patients may obtain opioids across the spectrum of our society from our known prescribers to different disciplines of prescribers. So we can find that out in our monitoring programs. We've talked about, at least, asking about drug abuse or street drugs, if you will. I guess the only category we haven't talked about are pets as the other source of drugs. I know that's very unusual, but the other big group of prescribers out there are veterinarians. And I know nothing about veterinary medicine or if they prescribe these types of pain medications because obviously, we're not humans. But it is something to consider. I'm going to throw you a curve ball here because there's one area that we haven't discussed and as we talked about looking at other substance use disorders. And that's screening for alcohol use. Not necessarily a disorder, but knowing how much patients might be drinking, since it is the most commonly used substance in the United States and the most common substance use disorder in the United States.
That's right. You say it's a curveball, but it's a really very logical question. So when we thinking about why many patients take opioids in the first place, a lot of times, it's dealing with that comprehensive pain. It's not just from one source. We know that, you know, patients who have pain will often turn to other substances to try to feel better. And that's a pretty natural thing. We didn't get fully into the screening, but that comprehensive intake process would look at other mental health conditions. So depression, using things like a PHQ-9 screen. We think about alcohol use. We think about tobacco use. I think alcohol is important to point out because alcohol has a depressant effect or a sedative effect. And when you combine that with opioid, which we talked about also being sedating, you add that to the risk of confusion and falls in an older adult, and those risks can all be magnified by each other. So certainly, important to screen not just for abuse but for use. And that's important to know when we're prescribing to talk about not taking these medications together, not combining them, storing them safely. And, you know, thinking about the risk of overdose. Addiction is, you know, not just a medical problem. But very often, people seek drugs or alcohol in response to, you know, complex suffering when they don't feel they have better options. And alcohol can be a part of that.
Okay. Great. Well, I think we've covered everything on my list. Anything on your list that we would -- if you'd like to talk about?
I think we hit the highlights. Let me see if there's any [inaudible]. We could talk a little bit about the cognitive effects.
Okay. If you want to go on that one.
Maybe I forgot for a reason.
There we go. So we talked a little bit about side effects, but cognitive effects are a category that can be a particularly tricky one in older adults who are taking opioids. So the challenge can be what came first? So we know that, you know, sometimes, patients report taking extra doses or being confused. And it's important to try to tease out whether that's a side effect of the medication or a sign of another process that's going on. So when our older adults report that, it doesn't always mean they're trying to abuse it or mean an opioid use disorder. Older adults may have cognitive disorders that go unrecognized. And that leads to things like unintentional overdose, combining medications. So things you would watch for would be signs that when patients start reporting that, you know, the pill doesn't help the pain but they feel bad if they don't take it, they're taking extra doses, they feel confused or even when that feeling, like that schedule of taking the opioids starts to control their life. We want to evaluate for what the source of that is. And we know that 50 to 80% of patients with chronic pain also have depression and anxiety. And so any of those things could lead to cognitive changes that are important to watch out for.
You know, for our patients who are in nursing facilities, are there any special or added areas of emphasis?
I think one area unique to nursing homes is that polypharmacy is almost always involved when there are overdoses. And this can be intentional or unintentional. So the obvious ones involve mixes with benzodiazepines and sedative hypnotics. Gabapentin is one of those that's been popularized as an attempt to conserve opioids, but it turns out we see an increased risk of harm with Gabapentin when it gets combined with opioids. There's an increased rate of unintentional overdose and a risk of harm and really no benefit when used for things like back pain. So in nursing homes, there tends to be a lot of PRN or as needed medications on a patient's regimen that can sometimes include medications like that and in combination that can be particularly concerning. If patients are in nursing homes, they will often have cognitive challenges that have led to their placement there. And there has been an overuse of antipsychotics and other medications that can have sedating side effects. And I think it's that interaction that tends to be a problem. In residential facilities, nursing homes, that is important to be aware of.
Okay. Yes. Well, I mean, obviously, structured living arrangements for older people are more common today. And it's important to know who's prescribing and who's administering those medications. One of the reasons we always ask patients to bring in all their pill bottles so we can check and see what's going on with that.
That's right. Pill counts, again, can be off not always because of the patient but because of patients that maybe around the patient or are using their medication. So, you know, I think we always have to assume a place of best intent in terms of why whenever we see an aberrancy in patient's behavior. Thinking about their living situation has all sorts of implications on how we prescribe. Thinking about what form of medication we use. Maybe that's an argument that we think about using a patch of fentanyl, something like that so that there aren't pills to easily go around or go missing from a bottle. At the same time, when you think about delivery mechanisms such as a patch, you have to think about pets or kids in the home. You don't want a patch to get swallowed by the dog or played with by a small child because those effects can be deadly. So there's lots of things to take into account in a patient's social environment when we're prescribing.
I've heard several times of patients with many, many, many patches applied. So living in that situation, patients really need to understand how they're supposed to use that patch and be able to do a return demonstration about that, otherwise, you could end up in a very serious situation.
That's right. I mean, a patch can be a good alternative if patients have difficulty swallowing or some of those things where you don't want a pill bottle around for the risk of that. But you can have too many patches just like you can have too many pills. We also have to think about in older adults, especially frail adults who don't have much subcutaneous tissue or fat anymore, that absorption from the patch can be compromised. And so really thin, frail, old patients, sometimes, will put multiple patches on because they're not getting an effect from it. And it's just really, that delivery method for the drug is not the best for the patient. Okay. Well, something for me to look forward to having less subcutaneous fat in the future. That's another story.
What about supplements and other dietary aids? Any issues, interactions that you can think of that are significant?
You know, unfortunately, there's not a lot of evidence that supplements have much of a role in chronic pain. So in older adults, we worry more about interactions with medications and problems than potential for benefit. Probably the most common one that people will think about using is glucosamine or chondroitin, more commonly now just glucosamine, especially for chronic knee pain. Unfortunately, although there was initial promise with it, there's not a lot of evidence that it's going to do much. So -- especially since we don't know what's in a lot of these formulations, it's not something we can really recommend. There's some low-quality evidence that things like turmeric, either in capsule form or in a lot of the powder form, can be an -- have anti-inflammatory properties for arthritis. Does it treat pain? That's a little bit less convincing. But some turmeric probably wouldn't hurt anyone.
Well, is it more effective than a known nonsteroidal anti-inflammatory drug?
So there's not a lot of evidence showing it's more effective than an NSAID or a nonsteroidal anti-inflammatory. Unfortunately, NSAIDs in particular in older adults can be somewhat problematic due to their increased risk of GI bleeds, as well as interactions with other medications, blood pressure, and taken chronically may lead to a whole host of problems. When you add to that, unfortunately, the evidence for chronic pain of NSAIDs is just not as good as we hope. It sounds nice because they are definitely safer than opioids, but there's only moderate quality evidence for a small improvement in pain. And there are also studies that have showed no difference in pain to a placebo when using those NSAIDs. So still maybe a rule to try first, given the relative benefit in harms compared to opioids. But in older adults, they have their own risk.
Well, the bottom line is tell your doctor about any prescribed medications, over the counter medications, supplements or diets that you may be using to address any condition so that there's a full knowledge.
That is for sure. We -- whenever we ask for medication lists, we want it to include things that we are prescribing or things that you have taken on your own. So always important to get that so we can come up with the best treatment plan, know what's worked, what hasn't.
Dr. Botsford, thank you for your time today and all of your great knowledge. Maybe we'll hear you again on another podcast.