Chronic non-cancer pain (CNCP) has been defined by the 2019 International Classification of Diseases version 11 (ICD-11) by differentiating between chronic primary pain and chronic secondary pain (Treede et al 2019). Chronic secondary pain is attributed to an underlying condition such as cancer (National Institute of Health and Clinical Excellence, NICE 2021a) whereas chronic primary pain has the pain condition predominating such as in fibromyalgia or low back pain (Treede et al 2019). Chronic primary pain is pain which has been present for greater than 3 months and is often out of proportion to expected healing times (NICE 2021a). The experience of chronic pain follows a biopsychosocial model of disease understanding from the work of Engel (1977) due to its close links to mental health. Social components include isolation, and deprivation, as well as the emotional aspects of stress and anxiety (NICE 2021a). CNCP is thought to affect between 35-51% of the United Kingdom (UK) adult population (Fayaz et al 2016).
Opioid crisis
Some patients with CNCP are treated with opioids amongst other adjuvant pharmacological therapies (BMA 2017, Appendix 1). However, it is commonly found that opioids are ineffective over time resulting in subsequent dose increases (Eccleston et al 2017). Stopping or reducing opioid drugs can be problematic due to unpleasant effects (Eccleston et al 2017).
In the late 1990's health care professionals (HCPs) were reassured by the pharmaceutical industry that patients prescribed opioids for pain would not become addicted to them (United States (US). In addition the early 2000's has widely been described as an era of opioid epidemic due to the increasing prevalence of CNCP and the liberalisation of laws which govern prescribing opioids resulting in a dramatic increase in opioid use (Manchikanti 2012). Prescribed opioids can lead to misuse, dependency and have led to more deaths than road traffic accidents, suicide, and deaths from cocaine and heroin combined (Manchikanti 2012). A total of 46,802 deaths related to opioid overdose were recorded in 2018 (Hedegaard et al 2020). In the United Kingdom (UK) death rates rose from 28 deaths per million in 2008 to 38.7 deaths per million in 2018 (Office for National Statistics (ONS) 2018).
Adverse effects from opioid prescribing can be experienced in as many as 80% of patients (Moore 2005). These include sedation, constipation, impaired cognition, and depression (Benyamin 2008). Long term treatment can increase hyperalgesia, paradoxically leading to an increase in pain (Colvin et al 2019). However, a small number of patients can obtain CNCP relief if the dose can be kept low and by avoiding daily use (FPM 2019). Although success of opioid therapy in CNCP is only marginal in the short-term with no proven long-term benefits (Chaparro et al 2014).
Non-pharmacological approach
The seminal work of Melzack and Wall (1965) introduced gate control theory where the physical manifestation of pain is culminated in pain transmitted via peripheral nerves to the Dorsal Horn at the base of the spine where messages are sent to the brain stem which acts as a switching station (Rhoads 2013). Over time patients can become sensitised to the pain experience therefore the aim of non-pharmacological approaches is to, de-sensitise the Dorsal Horn (Rhoads 2013).
Non-pharmacological approaches can include anti-inflammatory diet, yoga, massage therapy, acupuncture, tai-chi, and mindfulness which all have a documented therapeutic benefit (Lemmon 2020). Recent NICE guidelines recommend physical activity, psychological therapy, and acupuncture (NICE 2021a). However, evidence for their effectiveness is lacking (Windmill et al 2013, Eccleston et al 2017 and NICE 2021a). A compounding issue is that CNCP is difficult to treat, non-pharmacological alternatives are often controversial, and effectiveness can vary between individual patients (Matthias et al 2012).
Methodology and methods
Research paradigms incorporate philosophical worldviews which are a set of beliefs that guide action (Guba 1990). An ontology is the scientific study of ‘being’ and of ‘what is’ thereby fulfilling the notion of existence and reality (Crotty 2020). A further ontological assumption is one of interpretivism which seeks to gain knowledge through perception and interpretation (Bryman 2016; Crotty 2020). Through this methodology the researcher becomes personally engaged as they evaluate research participants' perspectives, which could potentially influence research findings (Al-Saadi 2014) leading to bias (Carroll et al. 1996). Therefore, reflexivity analysis in the form of a reflective diary (Appendix 2) will be utilised as the author has both personal and professional experience in dealing with CNCP.
An alternate paradigm to ontology is epistemology which seeks to understand how we make sense of the world around us (Crotty 2020). Hereby knowledge gained is subjective and personal involving greater involvement of the research participant which then rejects the scientific method as would be found in quantitative studies (Al-Saadi 2014). Therefore, the qualitative research method would be the most appropriate due to the richness of the data that can be obtained (Creswell and Creswell 2017). Qualitative research studies include grounded theory in their design base where the line of enquiry is borne out of the views of the participants in an inductive manner (Aveyard 2010). The phenomenology of the participants lived experience of CNCP will include an ethnographical perspective of the participants involved (Parahoo 2014).
A review of the literature was conducted using NICE Healthcare Databases Advanced Search (NICE 2021b) using the databases Cumulative Index to Nursing and Allied Health (CINAHL), British Nursing Index (BNI), PubMed, Embase and PsychINFO. A supplementary search was also carried out using Google Scholar. To enable the generation of search terms the acronym PICO was applied (Sackett et al 2000) (Appendix 3). For the search terms to relate to one another BOOLEAN operators were used (Appendix 4). The initial research resulted in 142 journal articles; exclusion criteria were applied to reduce the number of studies to a manageable size (Appendix 5) and to assist with the challenge of article selection. Articles were chosen after 2010 due to the shift in clinical practice away from using opioids from this time (Henry et al 2019).
After applying this method, 15 articles remained, 5 were rejected due to focusing on one type of non-pharmacological approach rather looking at them as a broader strategy. A further 5 were rejected due to the quantitative nature of the study leaving 5 qualitative studies to critique in the literature review which were selected to provide richer data surrounding factors influencing use of opioids (Seamark et al 2013). Each of the remaining 5 journal articles were put through McMaster critical review forms for qualitative studies (Letts et al 2007) and the main findings formulated in a theme matrix (Appendix 6).
Results
The findings of this literature review can be grouped into 3 themes that focus primarily on the patient (Lestoquoy et al 2017 and Kennedy et al 2017), the patient and HCP perspectives (Penney et al 2016 and Henry et al 2019), and thirdly HCP perspectives (Seamark et al 2013). Perspectives captured from the studies were chosen to illustrate each main point (Appendix 7) where the findings can be viewed pictorially (Appendix 8).
Patient perspective
The patient focused studies include an integrated medical group visit (IMGV) which is a new model for treating chronic conditions that combines group medical visits, mindfulness based stress reduction (MBSR) and evidence based medicine (EBM). The IMGV intervention included ten sessions with a primary care provider and meditation instructor designed to gather perspectives from low income and racially diverse patients, showing that prior to the IMGV patients reported that CNCP is isolating (Lestoquoy et al 2017). Additionally, CNCP can cause a loss of control due to the unpredictable nature of flare ups, as well as reliance on medication (Lestoquoy et al 2017). The second study which focused on older adults aged >= 50 years of age found that patient perceptions related to the severity of the pain, the efficacy of pain medication as well as concerns surrounding adverse effects, addiction, and tolerance (Kennedy et al 2017; Seamark et al 2013). The Horne Model builds on the self-regulatory model of disease which incorporates internal factors that include beliefs about medication (Horne 2005). Efficacy was weighed against risk with regard to acceptance of the need to continually rely upon pain medicine (Kennedy et al 2017).
Both studies raised concerns regarding navigating the care system (Lestoquoy et al 2017), access to specialists (Kennedy et al 2017) and a complex system which surrounds chronic pain management (Penney et al 2016). An external factor of The Horne Model highlighted by Kennedy et al (2017) is how family members can influence patient's management of CNCP as well issues with access to care. Following the IMGV intervention patients found they coped better with CNCP, leading to increased locus of control (Lestoquoy et al 2017). Furthermore an outcome of the Lestoquoy et al (2017) study showed that following engagement in IMGV patients were more engaged in non-pharmacological approaches to CNCP including meditation, mindfulness, and yoga (Appendix 7).
Patient and HCP perspective
The main findings of Penney et al (2016) included attitudes towards opioid use, with limited alternative options to manage CNCP, however acupuncture and chiropractic (A/C) care may have the potential to help pain with most participants stating A/C as helpful for short term relief (Penney et al 2016). It was found that opioid use emerged as a dominant theme in the data from both patient and HCP where opioids were frequently referred to when HCPs were asked about barriers and challenges when working with CNCP patients (Penney et al 2016). They found that patients may be unwilling to consider other options other than opioids in the context of limited alternative options (Appendix 7) but there was recognition that A/C can help patients provide short term relief from pain but can differ depending on acupuncture or chiropractic care (Penney et al 2016). However study participants were dissatisfied with the default to opioid medication (Penney et al 2016).
The second study addressing patient and HCP perspectives, looked at identifying patient statements which might indicate to the HCP a willingness to taper opioid use or embark on an alternative non-pharmacological approach (Henry et al 2019). They claim that patient statements suggesting an openness to try were common during primary care visits with over half (53%) of all visits included 1 clue, and one-fifth (21%) included more than 3 clues (Henry et al 2019). Fifty-eight percent of patients stated at least one opioid related adverse effect, 27% claimed 2 or more different adverse effects and 10% recognised 3 or more (Appendix 9) (Henry et al 2019). In response to patient clues, it was determined that HCPs responded less than half the time (43%) with no or minimal response, with the same proportion (43%) further exploring clues however much fewer (14%) responded sympathetically or empathically (Henry et al 2019).
Furthermore patient assessments that occurred during previously initiated and ongoing opioid tapering regimes were identified (Henry et al 2019). Tapering patients made 1.8 assessments for each made by a non-tapering patient (95% CI 1.06 – 3.1, P =0.03) and expressed 3.1 clues for each clue expressed by a non-tapering patient (95% CI 1.4 – 6.9, P=0.006) (Henry et al 2019), demonstrating significance of collaboration between patient and HCP.
HCP perspective
Lastly the study which looked at the HCP role in treating CNCP (Seamark et al 2013) found that HCPs viewed CNCP as different to treating cancer pain and cite using a stepwise approach to pain management. There was reported difficulty in assessment of the CNCP patient and the duration of use of opioids along with balancing side effects, tolerance and addiction (Seamark et al 2013 and Henry et al 2019). There was recognition that total pain relief may not be achieved in the CNCP patient as well as concerns surrounding secondary gains of accessing opioids including accessing benefits with an overall recognition that treating CNCP is different to treating cancer pain (Seamark et al 2013). The level of experience of the HCP as well as any involvement in significant events using opioid therapy resulted in variation in practice across the study group (Seamark et al 2013). However, lack of HCP training in managing CNCP was evident and reported as such by over half of the respondents who had received none (Seamark et al 2013).
Discussion
The IMGV intervention (Lestoquoy et al 2017) found improvements including integrating non-pharmacological self-management strategies that come some way to addressing the opioid overuse epidemic (Centre for Disease Control, CDC 2021). It also builds on previous qualitative studies where themes were found including loss of control due to the unpredictable nature of their condition and feeling of being misunderstood (Crowe et al 2017). The MBSR approach that was used as part of the IMGV has been known to lead to improvements in pain scores as well as mental health (Fjorback et al 2011).
Furthermore, participants in this study described living with CNCP as a process of grieving before finding a place of acceptance (Kubler-Ross and Kessler 2009). A key element to this is improving patient's subjective experience of pain providing an ability to move forwards with support (Lestoquoy et al 2017). Future planning of services for CNCP should heed these findings as the majority of treatment currently involves a 15-minute visit to a HCP in primary care which is too little time to support patients with self-management strategies (Lestoquoy et al 2017). A suggestion would be for the IMGV model to be applied to group consultations with the presence of specialist HCP's covering biopsychosocial aspects of care. After all it is the limited access to additional non-pharmacological services for the CNCP patient that drives the over-reliance on opioid therapy for pain management.
The second study focusing on patient perspectives by Kennedy et al (2017) is based on a self-regulatory model which has internal and external factors as its core beliefs surrounding disease and its treatment (Horne et al 2005). The internal factors of the Horne Model include pain severity and perceived efficacy of pain medication where efficacy was weighed against accepting of the nature of CNCP where pain relief is a necessity to function (Kennedy et al 2017). There was however a general acceptance by patients that strong opioids play a part in CNCP management including over the longer term (Kennedy et al 2017) which is at odds with the notion of aberrant behaviour leading to dependence (Robertson 2020). Furthermore, none of the participants addressed misuse of opioids including addiction or dependence to the same extent as other adverse outcomes (Appendix 8) (Henry et al 2019) which may be due to widespread knowledge mainly through the internet (De Boer et al 2007). Additionally stoicism of the older patient may mean they take pain medication less frequently and at a lower dose than prescribed which can often be seen in clinical practice (Sale et al 2006). Horne's model of medication adherence is of importance when seeking to optimise adjuvant medication in accordance with NICE (2009).
External factors particularly related to social support as well as with HCPs can help with coping (Reid et al 2015) as well as access to specialised care which was also a main finding of the IMGV intervention (Lestoquoy et al 2017). It is certainly true in primary care practice that patients rely on their HCP to co-ordinate care received where patients acknowledge the expertise of specialists but connectivity to them remains as issue (Kennedy et al 2017). Further external support given by family can offset patient misgivings about taking opioids which contrasts with misunderstanding which patients can perceive from the population as a whole (Kennedy et al 2017). However on close inspection of the Kennedy et al (2017) study the sample size can be reduced to 21 patients of relevance as the remaining 6 were not being treated with opioids but other pain-relieving adjuvants (Appendix 1).
Patients and providers of non-pharmacological alternatives were not always satisfied with the effectiveness of A/C particularly when CNCP was of longer duration and/or were heavily medicated (Penney et al 2016). Although, there are randomised control trials that indicate A/C has as an efficacy as good as medication (Lam et al 2013). HCPs suggest that opioids can foster a patient's passivity in relation to their motivation to self-manage as well as citing an unrealistic expectation by patients for zero pain (Penney et al 2016). Due to patient dissatisfaction of alternatives for pain relief there were discussions of over-the-counter medications to cope and function (Penney et al 2016). The theory of self-regulation of opioids (Paterson et al 2016) could be a potential barrier to self-management behaviours that offset opioid use (Kennedy et al 2017).
HCPs fear difficult interactions that can act as a barrier for discontinuing opioid therapy (Henry et al 2019). It was found that almost half the time (43%) HCPs did not respond to patient clues, suggesting room for improvement. However it would not be realistic to expect HCPs to further explore clues 100% of the time (Henry et al 2019) as well as constraints of time to facilitate discussions (Penney et al 2016). Patient-endorsed adverse effects were gathered in the data but were not always counted as clues even though this can give HCPs an opportunity to offer non-pharmacological alternatives (Penney et al 2016). The strategy of looking for, and exploring, clues can be likened to the approach of motivational interviewing techniques (Miller and Rollnick 2013) a patient-centred strategy to enable patients to change behaviour because of the listening and exploring of beliefs and attitudes that patients express (Henry et al 2019). There is an assumption that patient clues reflect a willingness to change, it is possible that patients have mirrored the HCP in a manner of social desirability bias or to present themselves in a better light (Henry and Matthias 2018). However to develop practice in primary care patients should be routinely asked about their opinions of opioids and their adverse effects which may convey a willingness to taper and try alternative approaches.
Interview questions were adjusted in an iterative process to reduce bias to allow for emerging themes whereby the same researchers used the same guides to conduct interviews (Seamark et al 2013, Penney et al 2016 and Lestoquoy et al 2017) displaying an audit trail of the methods used thereby increasing research credibility (Moule and Goodman 2014). Although there could have been a more inductive approach of grounded theory (Penney et al 2016) which corresponds to the development of more substantive theory (Parahoo 2014). Kennedy et al (2017) make use of a pragmatic approach identifying themes rooted in the data as interviews were transcribed verbatim. Critically, patients in the Penney et al (2016) study were not handed copies of their transcripts which could have left errors in nuancing as member checking was not included (Moule and Goodman 2014).
The stepwise approach to pain discussed in Seamark et al (2013) is based on the World Health Organisation (WHO 1986) analgesic ladder which was never validated as a tool for treating CNCP (BMA 2017). This has been seen in clinical practice and sparked the initial interest in seeking alternative ways in which to manage CNCP. Some HCPs in this study felt that they should explore alternatives to opioids which has been further developed in the NICE (2021a) strategy. Particularly as patients often present with a desire for quick relief from pain coupled with HCPs' discomfort in confrontation should opioids be refused (Penney et al 2016). However, HCPs displayed a balanced view to prescribing opioids although there was wide variation in experience and training (Seamark et al 2013). For example GPs stating in this study that in theory it is like prescribing for cancer pain but with a qualifying statement that they have a reluctance to move to stronger opioids (Seamark et al 2013).
There were concerns expressed over distinguishing true need for pain relief rather than for obtaining benefits (Seamark et al 2013) akin to Penney et al (2016) who found that HCPs expressed concern about “playing policeman” where further training regarding assessment of the CNCP patient would be welcomed. Although in primary care practice there is certainly awareness of caution around CNCP patients with a history of substance misuse (Seamark et al 2013). Furthermore, concerns were raised about harming rapport with their patients although the Henry et al (2019) study of exploring clues may go some way to addressing this. Previous work by McCracken et al (2008) found that one quarter to one third of HCPs would not prescribe opioids for CNCP however the Seamark et al (2013) study only found one, concluding that HCPs may benefit from further training, echoed by Kennedy et al (2017).
Limitations of the current literature review includes the perspectives captured in Appendix 7 which were chosen to reflect the main findings although there were many other opinions voiced. Additionally adding in the search term “qualitative studies” to my research strategy may have provided further appropriate work to critique. Furthermore, widening my search to include studies further back than 2010 years may offer useful insights in the way opioids were perceived particularly as the climate surrounding CNCP began to change from 2010 (Henry et al 2019).
Conclusion
This literature review has revealed 3 main themes that relate to seeking non-pharmacological approaches opposed to opioid therapy in CNCP. They relate to patient perspectives where the use of IMGV and Horne Model's can offer a way of increasing efficacy, and a greater understanding of the factors involved. Reviewing patient and HCP perspectives has highlighted the limitations of seeking alternatives to opioids. One solution may be to look at A/C treatment used early in the disease process to garner the best effects especially patients identified as anti drug therapy, however primary care practices often lack integrated multidisciplinary treatment options for this patient group.
While neither group are happy about it, opioids may still be a fall back solution during clinic visits. HCP's in primary care are in a good position to take into account the biopsychosocial factors that influence opioid use. There needs to be greater emphasis on educating patients that pain medicine is only one part which needs to be reinforced in clinical practice with a subsequent shift in expectation. Patient clues can be utilised to uncover opportunities to either reduce of stop opioid medication alongside a recognition that patients usually seek help while they are actually in pain. Indeed, the HCP focused study highlights the anxieties faced when trying to broach this difficult subject, and the need for more training. Future research would be beneficial in this area, particularly qualitative studies looking at the relationship between patient and HCP, working collaboratively to help find potential solutions to decrease long term opioid therapy, as the amount of good quality research in this area is lacking.
KEY POINTS
- Opioids have been used as standard treatment for CNCP in the past but lack efficacy and may cause patient's significant harm.
- CNCP is best approached by a biopsychosocial model of disease understanding.
- Perspectives can broadly be divided into 3 main themes that relate to the patient, communication between patient and HCP, and lastly HCP views.
- Perspectives gained can be used to enhance and inform clinical practice through greater understanding of the individuals involved.
REFLECTIVE QUESTIONS
- What is the prevalence of chronic pain patients in your practice area?
- How are chronic pain patients currently treated and how will this article enhance and inform your practice?
- Think of a patient that you have cared for, how can you approach their pain control differently, what communication strategy would you use and why?
- Reflect on your own personal experience of pain, or that of your friends or family, how has your perception of managing chronic pain changed to allow you to look after yourself and others better?