Nonopioid Analgesics and Adjuvants

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Nonpharmacologic Approaches to Pain Management
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Psychologic Treatmentsfor Chronic Pain

• Behavioral treatment
• Biofeedback
• Cognitive-behavioral treatment

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Behavioral (Operant) Treatment Model

• Operant focus on behavior
• Overt expressions of pain
• Use of medication
• Pattern of daily activities (eg, rest)

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Behavioral Treatment Intervention

• Change the consequences of (pain) behavior
• Medications administered on the clock
  ratherthan as needed
• Social responses, particularly spouses and
  families, shift from pain-related to activity-
  and wellness-related communication training
  often integrated
• Pacing of daily activities diminishes both
  aversive consequences of being active and
  positive consequences of rest record keeping,
  daily logs often critical

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Behavioral Treatment Outcomes

• Reduce pain
• Reduce anxiety
• Improve coping
• Increase activity level
• Reduce pain behavior

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Biofeedback Model

• Psychophysiologic
• Physiologic responses that are not typically
  under voluntary control or have become
  dysregulated
• Stress responses to pain and emotional
  challenges of living with chronic pain

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Biofeedback Intervention

• Learning to influence physiologic parameter
• Electromyography
• Galvanometry (electrodermal)
• Temperature
• Shaping of behavior
• Typically includes training in relaxation
  techniques

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Biofeedback Outcomes

• NIH Technology Assessment Panel
• Evidence is moderate for the effectiveness of
  biofeedback in relieving many types of pain
• Reduction in tension and migraine headaches
• Reduction in episodes of Raynauds

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Cognitive-Behavioral Treatment Model

• Affect and behavior are largely determined by
  cognitive processes
• Behavior results from a complex interaction
  between cognitive structures (eg, beliefs),
  cognitive processes (eg, automatic thoughts),
  overt responses, and the intrapersonal and
  interpersonal consequences of these multiple
  components

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Cognitive-Behavioral Treatment Intervention

• Integrates behavioral and biofeedback
  interventions
• Adds focus on cognitive structures and cognitive
  processes

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Cognitive-Behavioral TreatmentIntervention

• Sessions focus on identifying and challenging
  maladaptive cognitive structures and processes
• Homework focuses on personal experiments
  designed to test the validityof cognitive
  structures and processes

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Cognitive-Behavioral Treatment Intervention

• Emphasis on self-management
• Share 4 common components
• Education
• Skills acquisition
• Cognitive and behavioral rehearsal
• Generalization and maintenance

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Cognitive-Behavioral Treatment Outcomes

• NIH Technology Assessment Panel
• The evidence is strong for the effectiveness of
  (relaxation) in reducing chronic pain in a
  variety of medical conditions
• The evidence is moderate for the usefulness of
  cognitive-behavioral treatment in chronic pain

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Rehabilitative Approaches

• Physical therapy and exercise
• Work hardening and functional restoration

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Physical Therapy and Exercise

• Patient educationback school
• Best effects when integrated into a comprehensive
  rehabilitation program
• Electrotherapeutic and thermal interventions
• Exercise
• Recommended for chronic low back pain,
  osteoarthritis, fibromyalgia

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Work Hardening and Functional Restoration

• Aggressive physical therapy
• Work conditioning
• Psychosocial support

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Complementary/Alternative Approaches

• Spinal manipulation
• Acupuncture

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Complementary/Alternative Approaches

• Spinal manipulation
• Study quality is generally poor and findings
  inconsistent across studies
• Overall, studies suggest efficacy forlow back
  pain
• Subgroups of individuals may benefit more

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Complementary/Alternative Approaches

• Acupuncture
• Reviews of the available studies support the
  efficacy of acupuncture for musculoskeletal pain,
  recurrent headache, osteoarthritis knee pain, and
  possibly fibromyalgia

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