Clinical Translation: The Importance of Behavioral and Addiction Treatment Recommendations for Patients with Chronic Pain

Clinical Translation:

The Importance of Behavioral and Addiction Treatment Recommendations for Patients with Chronic Pain

Margeaux Cannon, Lisa M. McAndrew, Alye Brunkow, & Jessica L. Martin

The University at Albany, State University of New York

Margeaux Cannon

University at Albany 

Opioids are often prescribed for patients with chronic pain, even though the long-term risks (e.g., addiction, misuse, overdose) are greater than the long-term benefits (Dowell, Haegerich, & Chou, 2016; Hengstebeck et al., 2017; Krebs et al., 2018). Effective alternatives to opioids for long-term pain treatment are available, such as cognitive behavioral therapy (CBT; Kerns, Sellinger, & Goodin, 2011; Morley, Williams, & Eccleston, 2013), but it is not known whether behavioral treatments are being recommended to and used by patients with chronic pain, nor whether patients are even interested in these less-risky approaches to pain management. 

Recently published in The Journal of Pain by Brunkow & Cannon, et al. from the University at Albany and the VA New Jersey Health Care System, East Orange, New Jersey VA, “Doctor recommendations are related to patient interest and use of behavioral treatment for chronic pain and addiction,” addresses the question of whether patients with chronic pain are interested in behavioral treatments for their pain and addiction, and suggests factors that may be related to behavioral treatment interest and use. The authors collected an online sample of 1050 adult patients in the United States with chronic pain and asked about interest in and use of treatments for chronic pain, including CBT and medication. The survey also asked questions about opioid misuse and addiction treatment and if the patient had ever received a recommendation from their doctor for addiction treatment. 

Patients were more likely to have used medication than behavioral treatment for pain or addiction treatment, and were more likely to have received a recommendation for medication than behavioral treatment for pain or addiction treatment. Patients were generally interested in both medication and behavioral treatments for pain and less interested in treatment for addiction. Importantly, patients who received a recommendation for a particular treatment were significantly more likely to be interested in and have used the treatment. 

These findings also show that medications are still the primary treatment recommended to and utilized by patients with chronic pain. However, findings also suggest that patients who receive recommendations for treatments from their doctors are more interested in and more likely to have used these treatments. Although patient interest in behavioral treatments is high, utilization and recommendations are relatively low. Therefore, instead of focusing public health efforts on convincing patients to consider behavioral treatments, efforts are needed to encourage providers to effectively make recommendations for behavioral treatments to their patients with chronic pain. Simultaneously, providers must be aware of the risks and limitations of medicinal treatments for chronic pain. 

The study also found that those at risk for opioid misuse (i.e., 63% of respondents who used opioids) were more interested in the behavioral treatments than those who did not screen positive for opioid misuse. This finding goes against the common assumption among providers that patients who use opioids will be drug seeking and opposed to alternatives to opioids (Cooper & Nielsen, 2017). It is also notable that while 63% of participants who use opioids screened positive for opioid misuse, only 23% of patients using opioids had received a recommendation for addiction treatment. This finding may indicate a need for providers to increase addiction screening efforts, or the need to train providers on effective ways to talk to their patients about addiction and addiction treatment options. The data suggests that making recommendations for addiction treatment to this high-risk population could increase their interest in and eventual engagement in addiction treatment. 

References

Brunkow, A., Cannon, M., Graff, F. S., Martin, J. L., Hausmann, L. R., & McAndrew, L. M. (2020). Doctor recommendations are related to patient interest and use of behavioral treatment for chronic pain and addiction. The Journal of Pain. https://doi.org/10.1016/j.jpain.2019.12.008

 Cooper, S., & Nielsen, S. (2017). Stigma and social support in pharmaceutical opioid treatment populations: A scoping review. International Journal of Mental Health and Addiction, 15(2), 452-469.

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids   for chronic pain—United States, 2016. JAMA, 315, 1624-1645. 

Hengstebeck, E., Roskos, S., Breejen, K., Arnetz, B., & Arnetz, J. (2017). Clinical pain research: Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study. Scandinavian Journal of Pain, 17, 397-402.

https://doi.org/10.1016/j.sjpain.2017.09.021

 Krebs, E. E., Gravely, A., Nugent, S., Jensen, A. C., DeRonne, B., Goldsmith, E. S., ... & Noorbaloochi, S. (2018). Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA, 319, 872-882.

 Kerns, R. D., Sellinger, J., & Goodin, B. R. (2011). Psychological treatment of chronic pain. Annual review of clinical psychology, 7, 411-434.

 Morley, S., Williams, A., & Eccleston, C. (2013). Examining the evidence about psychological treatments for chronic pain: time for a paradigm shift?. Pain, 154(10), 1929-1931.