Non-Pharmacologic Approaches to Managing Pain in Older Adults

1. Cary Reid, MD, PhD Irving Sherwood Wright Associate Professor of Medicine Co-Director, Cornell Translational Research Institute on Pain in Later Life Division of Geriatrics and Palliative Medicine Weill Cornell Medical College New York, NY Non-Pharmaocologic Approaches to Managing Pain in the Older Adult

2. DISCLOSURE(S)

3. MULTIMODAL APPROACH TO PAIN MANAGEMENT INTERVENTIONAL APPROACHES PHARMACOTHERAPY OLDER ADULT COMPLIMENTARY APPROACHES PSYCHOLOGICAL MODALITIES PHYSICAL MODALITIES

4. Non-Pharm Approaches Psychological Exercise Physical therapy Heat/cold Massage Complimentary Physical • CBT • Self-management programs • Mindfulness meditation • ACT • Tai Chi • Yoga • Acupuncture • Nutritional supplements

5. Agenda • Why should we focus on non-pharm approaches in this population? • Review prevalence studies regarding use of non-pharmacologic approaches • Present guideline recommendations • Summarize evidence base for specific approaches • End with practice & research recommendations

6. Why Focus on Non-Pharm Approaches? We are confronted with the fierce urgency of now. Martin Luther King, Jr.

7. Need to Focus on Non-Pharm Approaches • Age increases risk for adverse drug events (ADE) • Older (vs. younger) adults up to 7 times more likely to experience ADE that requires hospitalizations1 • Risk for ADE increases with polypharmacy and multimoribidity2 • Mediated by physiologic changes • Decreased liver and kidney function/alterations in way drugs distribute in body (water/fat ratio) • Physicians fear causing harm/patients fear pain meds and ADE’s 1Salvi et al Drug Safety 2012;35(Suppl 1)29-45. 2Davies et al. Br J Clin Pharm 201580:796-804

8. New York City Older Adults with Chronic Pain (N=155) • Pain medications are dangerous: 66% • I know someone who has been harmed because of taking a pain medication: 41% • I take as little pain medicine as possible because they are addictive: 72% • I take pain medication infrequently because if you take it too often, they stop being effective: 62%

9. Rationale for Focusing on Non-Pharm Approaches • Costs of analgesic medications • Annual cost of analgesic prescriptions for adult patients ≈ 18 billion US dollars1 • Augmenting use of self-management approaches (e.g., exercise, psych approaches) could contribute to significant cost savings 1Rasu et al. J Managed Care and Specialty Pharm 2014;20(9):921-28.

10. Rationale for Focusing on Non-Pharm Approaches • Opioid epidemic • 165,000 deaths in US from 1999-2014 • Exceeded 33,000 for first time in 20151 • Deaths/overdoses disproportionately affect young and middle-aged adults, but...... • Significant cause of morbidity in older adults • ≈1/3 of Medicare Part D recipients in US filled at least one opioid prescription in 20161 • 3.6 million (12%) filled prescriptions for at least 6 months1 • Opioid use on rise in Australia and UK2,3 1https://oig.hhs.gov/oei/reports/oei-02-17-00250.pdf2Blanch et al. Br J Clin Pharmacol 2014;78(5):1159-66. 3 Giraudon et al. Br J Clin Pharmacol. 2013;76(5): 823–824.

11. Another Rationale: Small Evidence Base No. Articles Non-pharm or non-drug (tw.ab.) + chronic pain or musculoskeletal pain or non-cancer pain + older adult or elderly

12. Non-Pharm Versus Osteoporosis Contrast 12,472 56:1 ratio No. Articles 3,943 1,125 385 79 Osteoporosis (ti.ab.) + older adult (ti.ab.) or older individual (ti.ab.) or elderly (ti.ab.)

13. Non-Pharm Versus Cancer Contrast 19,734 88:1 ratio No. Articles 9,169 5,083 3774 1221 Cancer (ti.ab.) + older adult (ti.ab.) or older individual (ti.ab.) or elderly (ti.ab.)

14. Another Rationale: Many Older Adults Already Using Non-pharmacologic Approaches Name, Title | Session

15. Perceived Helpfulness of Approaches1 1Turner et al. Archives Phys Med Rehab 2017 (epub ahead of print) 2Response set = 4-point Likert scale with 4 = very helpful.

16. Epidemiology of Non-Pharm Approach Use by Older Adults • Significant minority using techniques • Perceived helpfulness/value substantial • Range of reported use is quite large • Exercise: 2-64% • Massage: 5-58% • No consistent patterns identified by location (13 studies: US, Europe, Asia and South America)

17. Knowledge Gaps • Use patterns and benefits not well characterized • Where did those who employ techniques learn about them? • Are users different than non-users? • What factors help to promote engagement and sustained use over time? • Provider/family support? • Access? • Are patient (or provider) expectations/concerns about value of approaches playing a role?

18. Guideline Recommendations

19. Specific Recommendations AGS = American Geriatrics Society; APS = Australian Pain Society; ACR = American College of Rheumatology; EULAR = European League Against Rheumatism; BPS/BGS = British Pain Society; British Geriatrics Society NR= No recommendation

20. Review Evidence Base Underlying • Psychological approaches • Exercise • Tai chi • Yoga

21. Psychological Interventions CBT: Modify maladaptive pain behaviors; equip patients with behavioral/cognitive pain coping skills; behavioral activation Self-Management Programs (e.g., Arthritis Self-Help Program): Focus on problem solving, goal setting/taking action, coping skills training, communication skills training and pain education

22. CBT Versus Self-Management Programs • Lay-person led • Communication skills training • Emphasizes importance of exercise • Therapist led • Focus on cognitive restructuring • More attention to relapse prevention Self- Management Programs CBT • Behavioral activation (goal setting, problem solving) • Coping skills training • Emphasize patient self-management

23. Other Psychological Interventions • Mindfulness Meditation • Work to change negative thoughts/emotions • Learn and practice mindfulness techniques e.g., breathing/walking • Acceptance & Commitment Therapy • Promote acceptance attitudes • Focus on maintaining important role functions despite pain

24. Conducted Meta-Analysis of Psychological Intervention Use Among Older Adults • Searched databases (Medline, PsychInfo, Embase, Cochrane) from inception to May 2017 • Included studies evaluating psych interventions for chronic non-cancer pain • Sample mean age = 60+ • Employed control group • Published in English

25. Participant Characteristics Most studies enrolled participants with musculoskeletal pain (17/23 = 74%);duration of pain reported in 12 studies, mean (sd) duration 15.6 (13.2) years

26. Study Characteristics 1Two employed mindfulness meditation; 1 employed acceptance and commitment therapy.

27. Study Characteristics

28. Number of Studies Reporting Outcomes Post-Rx: At completion of treatment, typically 10-12 weeks. Mid-term: 3 to 6 mos. Long-term: More than 6 mos.

29. Number of Studies Reporting Outcomes Post-Rx: At completion of treatment, typically 10-12 weeks Mid-term: 3 to 6 mos. Long-term: More than 6 mos.

30. Primary Treatment Effects Small = 0.20-0.49; Medium = 0.50-0.79; Large = ≥0.80. 1p < 0.10; 2p < 0.05; 3p < 0.01.

31. Primary Treatment Effects Small = 0.20-0.49; Medium = 0.50-0.79; Large = ≥0.80 1p < 0.10; 2p < 0.05; 3p < 0.01.

32. Do Treatment Effects Vary by Patient, Therapy, and Study Characteristics? • Patient • Age, sex, race/ethnicity, pain type (musculoskeletal versus other) • Therapy • Type (CBT vs. self-management vs. other) • Number of therapy sessions • Mode of delivery (group vs. individual) • Study • Year of publication, methodologic quality score

33. Group Versus Individually Delivered Therapy

34. Treatment Effects as Function of Patient Age 1Williams et al. Cochrane Database Systematic Review 2012l(11):CD007407. All RCT studies, N’s range from 308 to 1148 for these outcomes.

35. Room for Optimism? • Combined CBPSM program + exercise therapy delivered jointly by psychologist & physical therapist • Participants ages 65+ with chronic pain • Two-hour sessions twice weekly x 4 weeks = 16 total hours • Measured outcomes at post-treatment and one year 1Nicholas et al. Pain 2013;154:824-35. 2Nicholas et al. 2017;158:86-95.

36. Effect Sizes of Combined CBPSM + Exercise Intervention Small = 0.20-0.49; Medium = 0.50-0.79; Large = ≥0.801p < 0.10; 2p < 0.05; 3p < 0.01.

37. Review Evidence Base Underlying • Psychological approaches • Exercise • Tai chi • Yoga

38. Exercise and Pain Meta-Analyses Uthman et alBMJ 2013;347:f5555.; Fransen et al. J Rheumatol 200936:1109-17.; Juhl et al. Arth Rheumatol 2014;66:622-36.; Waller et al. Phys Therapy 2014;94(10):1383-94.

39. Primary Results Small = 0.20-0.49; Medium = 0.50-0.79; Large = ≥0.80 Uthman et alBMJ 2013;347:f5555.; Fransen et al. J Rheumatol 200936:1109-17.; Juhl et al. Arth Rheumatol 2014;66:622-36.; Waller et al. Phys Therapy 2014;94(10):1383-94.

40. Factors Moderating Treatment Outcomes? • Benefits most likely to accrue with: • Combined strength + flexibility + aerobic approach1 • 3 or more supervised sessions per week2 • Those with severe versus mild/moderate OA received same benefit2 1Uthman et alBMJ 2013;347:f5555.; 2Juhl et al. Arth Rheumatol 2014;66:622-36.

41. Other Results Regarding Exercise • Not all studies reported adverse events, among those that did: • No significant injuries • Few drop outs on account of injury/pain flares • Do treatment benefits persist? Meta-analysis of walking among patients with chronic musculoskeletal pain (mean age 57)1 • Reduction in pain documented at post-treatment but not beyond 1 year (6-8% reductions) • Improvements in function documented at post-treatment and after one year (6-9% improvements) 1O’Connor et al. Arch Phys Med Rehab 2015;96:724-34.

42. Review Evidence Base Underlying • Psychological approaches • Exercise • Tai chi • Yoga

43. Evidence Underlying Tai Chi • Several meta-analyses evaluated effects of treatment among patients with OA and/or chronic musculoskeletal pain1-3 • Treatment effects documented • In moderate range for pain, function, stiffness, and QOL • Do not persist over time (?adherence issue?)2 • No significant safety issues reported 1Lauche et al. Compl Ther Med 2013;21:396-406; 2Yan et al Plos One 2013;8(4):e61672; 3Hall et al. Arthr Rheum 2009;61(6):717-24.

44. Evidence Underlying Yoga • Two meta-analyses identified evaluated effects on non-elderly patients chronic low back pain1 or mixed pain types2 (small Ns, short study periods) • Treatment effects documented in moderate range for reductions in pain and pain-related disability • No significant safety issues reported • One pilot study documented benefits of chair yoga on pain and physical function (mean age = 75)3 1Holtzman et al. Pain Res Manage 2013;18:267-72; 2Bussing et al. J Pain 2012;13:1-9; 3Park et al. J Am Geriatr Soc 2017;65:592-97.

45. Summary of Evidence • Psychological therapies have small average treatment effects • Effects are strongest in treatments delivered using group approach • Treatment effects of exercise, tai chi, yoga appear to be in the moderate range • Treatment effects decrement over time regardless of intervention modality • Treatments appear to be safe • Can tailoring non-pharm treatments to needs/limitations of older adults enhance outcomes?

46. Practice Recommendations • Recommending non-pharm, i.e, psychological, exercise, tai chi, yoga, approaches to older adults with chronic pain is supported by literature • Modalities that are accessible and affordable • Practitioners should learn (and share with patients) basic information about non-pharm approaches • Inquiring about treatment expectations (benefits/concerns) also important to do • Leveraging social supports to encourage patient continued use of techniques is warranted

47. Research Recommendations • Better understanding of factors mediating treatment effects is needed • Better understanding of treatment moderators: Which patients are most likely to benefit? • Need to develop age-appropriate psychological interventions that leverage behavioral science research in areas of temporal horizons, emotional and cognitive processing • Can delivering techniques as part of routine practice enhance treatment outcomes? • More research on role of mHealth technologies as tools to help deliver treatments/promote adherence over time

48. THANK YOU!