The broadcast is now starting. All attendees are in listen-only mode. Good afternoon, I am Dr. Ann Schreier and it is my pleasure to welcome you to ASPMN's ninth year series of webinars that focus on the use of opioid therapies for the treatment of pain, opioid dependence and on the safe use of opioids in the treatment of chronic pain. This series is one of the many resources available by the Prescribers Clinical Support System, a program that is funded by the Substance Abuse and Mental Health Services Administration. It's a collaborative project led by the American Academy of Addiction Psychiatry with a number of professional organizations. On the last slide, you will find a list of these organizations. You are able to obtain nursing continuing education credits for this presentation. You need to participate through the question and answer period in order to receive the continuing education. Detailed instructions concerning the CE credits will be given at the end of the presentation. Now, a few quick housekeeping notes before we begin today's presentation. Please feel free to ask questions during the session. Please, if you are using a cell phone to view the webinar, refrain from texting unless you're submitting a question. In the upper right-hand side of your screen, you will see a control panel. In the lower portion of that panel, participants can type in a question or comment and submit it to the webinar organizers. You can do this at any time during the presentation. We will reserve about 10 minutes at the end of the presentation for questions and answers. If we are unable to get to all the questions, the presenters have agreed to respond to them in writing. The slides were sent to you by an email earlier today. The webinar presentation slides and questions and answers will be posted on the ASPMN website tomorrow afternoon under professional development. You go to education, then PCSS webinars, and that website is www.aspmn.org. The slides will also be available through the PCSS website in the near future. That website is www.pcssnow.org. Today's presentation is Non-Opioid Symptom Management Strategies for Populations Prescribed Opioids. Our speaker today is Dr. Marion Wilson. She is an associate professor at Washington State University College of Nursing in Spokane, Washington. As a registered nurse with more than 25 years of experience in direct patient care and symptom management, her research focuses on undertreated symptoms among adults prescribed opioids for persistent pain and on opioid use disorder. She is certified in pain management nursing from the American Nurses Credentialing Center and the American Society for Pain Management Nursing. She has received funding from the National Institute on Drug Abuse to investigate opioid dose effects on adults with persistent pain after engaging in an online pain self-management program. She has been funded by the National Institute of Health Center for Complementary and Integrative Health to study the relationship of pain and sleep in veterans and presently serves as project lead for an interprofessional education project funded by the Substance Abuse and Mental Health Services Administration. That grant teaches health science students about medications for addiction treatment in the context of persistent pain. Many of her 70 plus peer reviewed publications focus on symptom management for adults with persistent pain or opioid use disorder. She presently serves on the Board of Directors for the Pacific Northwest Chapter of the American Society for Pain Management Nursing and has served on the ASPMN National Organization on the Nominating Committee, Chapter Resource and Membership Committee, Diversity, Equity, Inclusion and Belonging Committee and is on the Editorial Board of Pain Management Nursing which is the official journal of the American Society for Pain Management Nursing. Welcome Marion. Thank you for that wonderful greeting and thank you all for being here today. I come to you today from the Inland Northwest which is about a five to six hour drive to the Pacific Ocean and it's on the border of Washington State and Idaho. I want to first acknowledge the land on which our campus sits is the traditional home of the Spokane Tribe of Indians and I want to acknowledge the original caretakers of this land. Our College of Nursing has satellite branches across the state. All the sites you see on the screen in those little red dots, that is where we reach across the state of Washington. The research I will share today includes participants from this region of the country with chronic pain and those with opioid use disorder. The views I share today are influenced by their perspectives for which I am grateful that they have provided and they may not represent all other populations. I have no conflicts of interest to disclose. I do want to acknowledge the gratitude I have for all of the frontline workers. Any of you here today, thank you for all you have done and continue to do. Here are our objectives for the hour and I won't read them to you. You have them on your handouts but I do want to talk just a bit more to help people understand the patient's perspectives regarding their symptom burdens. And overall, share research that emphasizes the undertreated symptoms in an effort that we can do better by our patients who are suffering with pain. I'd like us to think about how we can encourage new approaches to symptom assessment and the integration of non-opioid treatment options and ultimately to empower the people with pain to improve their quality of life and the quality of life for healthcare workers. And I mentioned healthcare workers because treating pain really can help healthcare workers. We know right now about half of our COVID-19 frontline hospital workers are suffering with stress, more than a quarter with depression and anxiety. We also have to recognize these are some normal emotional responses to crisis. Burnout, compassion fatigue, post-traumatic stress disorder, these are all linked to work stress and witnessing patients suffering and unrelieved pain is stressful. I wanna take just a minute to mention moral injury. This is a type of psychological distress that can result from actions or the lack of actions that will violate somebody's moral or ethical code. It's a term that's been used in the military and it accompanies that feeling of guilt or shame when you're facing overwhelming demands. Moral injury has been present in healthcare historically and in my own career, I can think back to when I first started in the late 80s when we had HIV and AIDS emerging, we would have young men in our hospital unit who sometimes would have no visitors at all because they were being shunned because of their lifestyle. So that was a moral injury to those of us that had to witness that kind of isolation. And I know today we have a great crisis and there are similar feelings that are probably coming up in nurses that are caring for patients with COVID. We also had in the 1980s, the WHO ladder that was started really to focus on cancer pain management. And I was one of those nurses back then who would spend a lot of time advocating for patients with cancer to be sure we would get them opioids. So I just want to make clear, I am not anti-opioid in any way. I think they do a wonderful job. I've given out thousands of opioids in my career and we know that they work really well when people need them for pain. We also know that that unrelieved pain of patients can transfer onto caregivers as this moral injury, which can lead to depression, PTSD, and suicidality. And as we're talking just a moment about suicide, I do want to put the suicide prevention lifeline on the screen and encourage people to use that if they need to talk to someone and share that with their coworkers and your patients if you have people coming to you with feelings of suicidality. There's also safety to consider right now in this whole climate of reducing reliance on opioids. Patients sometimes get very angry if they are told they cannot have opioids for their pain. So we have not only depression and suicide, but also a possibility of violence against our clinic staff and our healthcare providers. The FDA recognized a problem and they came out with this safety communication identifying harm reported from sudden discontinuation of opioid pain medicines would require label changes to guide prescribers on gradual individualized tapering. And I really want to highlight this word individualized because we still don't have great evidence showing us exactly how we should taper opioids safely when it seems like the right thing to do. So it's still a trial and error process. And it's important to see that each patient has their own individual needs. We have to consider that. As it was stated by Dr. Madara, it's clear that the CDC guideline has harmed many patients because they were misinterpreted in some cases to mean that we don't use opioids for pain anymore. And that really was not the intention. The intention was to reduce harm from opioids. Abrupt cessation of opioids can lead to symptom exacerbations, illegal use of drugs, severe opioid withdrawal and depression and suicidality. There's more and more evidence that stopping opioids without a carefully thought out plan can be very dangerous. So I just want to really stress that point before we start talking about what else a person might do in addition to, or instead of opioids. The American Medical Association recommended revisions to those CDC guidelines to ensure that patients are not denied appropriately prescribed opioids for the management of pain. So let's think a minute about who actually is prescribed opioids. We have our people with pain. They come in with an acute injury. They might have opioids for short term. And then there's those long-term chronic or persistent pain people who may have been on opioids for a long time and they want to continue those opioids. We also have people with opioid use disorder who will sometimes receive opioids in order to manage their symptoms, their withdrawal symptoms, their craving for the drug. And sometimes they may have pain on top of that too, but the prescribed opioids are not meant to treat the pain. They're meant to treat the addiction. So if you have any thoughts about how the needs of these two populations might be the same and how they may differ, feel free to share that in the chat. Any special needs or any complications maybe you've seen in your experience with these two different populations who might receive opioids. One thing that I like to point out is that they both may receive some roadblocks when they're trying to have pain management. The access to non-pharmacological pain management has been recognized as a priority to decrease the opioid use and reduce human suffering. The people with opioid use disorder, they may fear using opioids actually because it may spark a recurrence of substance use. Providers may fear prescribing them opioids or feel ill-equipped to prescribe for someone who has both pain and opioid use disorder. Then the people with persistent pain, they may lose access to their opioids due to regulatory concerns, the loss of their provider when somebody moves or retires or lose their license for prescribing opioids. There's a host of people that are in a bind then and need to find some way to have access to the opioids they were used to getting. Otherwise they too will be thrown into an acute withdrawal in some cases, which can be quite frightening and unpleasant. Some states require a pain specialist for long-term use of opioids and those can be few and far between. So there could be barriers to finding that person to prescribe the opioids even when it's considered appropriate. Certainly we have trouble with finances, transportation and issues like that. So not everyone will have easy access to opioids even when they're needed. Both of these populations may have inadequate or undertreated symptoms. And it's known through some research already that poor symptom control can trigger substance use or substance misuse. And by misuse, I mean, maybe they're using that opioid for reasons other than it was prescribed. Maybe they're using it to help them sleep, not for their pain. Maybe they're using it for anxiety. So those kinds of behaviors can actually trigger inappropriate substance use or dangerous substance use. Most, more than 50% of United States adults with a substance use disorder have chronic pain actually. And with opioids, about 74% on average will have chronic pain on top of their substance use disorder so that's important to recognize. So within this population, there really is a high need for non-pharmacologic options because of the complication of ordering more opioids for pain on top of opioids that you may already have for your substance use disorder, for example. So in this program, when I'm talking about pain management, I'm just going to neatly divide it into two categories of pharmacological and non-pharmacological. And pharmacological, by that I mean, any kind of medicines really, so it can be opioids and we have lots of different ways opioids can be delivered or non-opioids like steroid injections, anti-inflammatory drugs, things of that nature. The non-pharmacological, one of the preferred terms now is complementary and integrative health. It used to be called complementary and alternative modalities, but this new term is preferred because it emphasized that these multimodal treatments are no longer an alternative, but they're really an essential component to providing a biopsychosocial spiritual approach to pain care or a holistic approach to pain care. So they're not an alternative, it's a combination of techniques that's often ideal to address the multiple mechanisms of pain relief. So even though they have an opioid, adding something to that opioid may make their pain management better by the combination of treatments that they're having. So one of the problems with pain research is that there are a lot of different kinds of pain and I have a few here on the slide, but there's probably many more that you could think of. So when you're researching pain, sometimes you'll see the study just narrowly focuses on a particular type of pain, like maybe they're focusing on migraines, but for many studies and the studies I've done, often we just lump all those pains together and we consider that a chronic pain population prescribed opioids, because they do have some common traits, even though there's unique things about each different type of pain. Within those populations, within those categories then, also we have complex comorbidities often occurring. For example, anxiety and depression and post-traumatic stress disorder often occur with pain. We also have the limitations of self-report in pain assessments. Of course, the person's perspective is really important, but there's also limits in knowing how well we're doing managing pain, if for example, the person doesn't communicate very well or they have a lot of inconsistency in how they're able to verbalize their pain or report their pain. We also know there's a lot of variation in how people respond to pain treatments. So when you have a randomized controlled trial and a lot of variation, it can be hard to actually find a significant difference between the two different groups. If you're comparing, let's say a treatment and a control of some kind, sometimes it's hard to find a difference between those two groups. Another thing that can happen is the placebo effect is very common in trials. And you may think of a placebo effect as being something bad, but it's actually good. It's part of why we can help pain in so many ways because the brain is where we process pain and the brain is also where we can help to relieve pain. So when we have a placebo effect, sometimes we're relieving pain, even though the mechanism of the pain relief is not what you intended. It's something more psychological than physical, perhaps, for example. So when we have these limits in the research, it's hard to have strong evidence that something for pain really works well for all people. So again, it's why it's important to treat the individual. We're not treating the group mean. Just because a particular intervention doesn't work for everyone or it doesn't work for most people doesn't mean that it won't work for you. So I think it's really important for clinicians to grasp that concept when they're looking at options for patients and realize sometimes you're going to need a lot of options to find the right match for that particular patient. And we'll talk more about that going forward. I do just want to spend just a minute here talking about how pain can promote and reinforce the use of substances. For one thing, when you use a substance such as alcohol, opioids, cannabis, benzodiazepines, you have a negative reinforcement. If it relieves your pain, you may be pain-free and that's very reinforcing, meaning I want to do more of that. My pain's better. You also may have on top of that a bit of euphoria. So you may have a nice pleasant feeling that you get when you drink some alcohol. So on top of the negative reinforcement, you have this positive reinforcement with the euphoria, doubly reinforcing, making it very easy for people to continue to want to manage their pain with substances, even though over the long term, they may start to have some problems. And pain and substance use can actually interact in a feedback loop that could worsen both conditions over time. For example, with alcohol and opioids, we know that they can actually interrupt good sleep. When we don't have good sleep, we have increased pain. So even though on the short term, it may feel better, over the long term, they could have more trouble getting the pain under control because they're not getting a good night's sleep and all types of physiological problems occur when you don't get good sleep. You also may have some withdrawal happening or some hyperalgesia or hypersensitivity to pain that could happen with some of these substances. For example, there's research I have read recently showing that many people don't recognize when they're having withdrawal symptoms of cannabis. If they're regular cannabis users and they stop using it for some reason, they could actually have some withdrawal feelings and they don't attribute it to the cannabis. They may not recognize that's withdrawal that's happening. So that's how substances can be a little tricky when you're trying to use that as your only way of managing pain. Pain and substance use disorders share neurophysiological patterns. And by that, I mean those neural systems, those networks in the brain are shared with pain and substance use, and they're both associated with surges of dopamine, the reward, motivation, and learning centers in the brain. Both pain relief and addictive drugs are reinforcing in the brain circuitry and can lead to a preoccupation or craving for analgesic drugs. If you know taking that drug is going to get rid of your pain, what I've heard from participants in our studies is they actually are craving the pain relief. They're not craving the euphoric high. They're craving the pain relief. It's very reinforcing. So I think that's important to understand when, for example, you have a person that seems resistant to stopping or tapering from their opioids, you must understand in part it's because it's effective. It's actually making them feel better. So you're going to have to replace that with something that will be equally reinforcing. You're going to have to interrupt that reinforcement that's going on. Discerning pain behaviors from substance use behaviors can be very difficult, and I would challenge anyone who thinks that they could do that in a five-minute visit. I think it's very difficult, yet it's a really important distinction to try to figure out what's going on with your patient, whether it's undertreated pain or a substance use disorder developing. A wonderful paper has come out, Monhopra and Becker, and they are saying treating chronic pain and substance use disorder as separate entities can miss the complexity of the whole individual. Coexisting problems necessitate an integrated multidimensional therapeutic approach. So we must treat the addiction and the pain. No longer can we say to people who come to an opioid treatment program, we don't do pain here. We don't manage pain here. We must do something to help them with that symptom. That is my true belief after speaking to hundreds of people in these situations. So when we talk about transitioning to opioid use disorder, there really are still gaps in our understanding about how people move from appropriate opioid use for pain and into opioid use disorder. The true incidence is really hard to know, but it seems that an estimated 15 to 26% of people who are prescribed opioids for chronic pain will misuse. And as I mentioned, misuse can mean just, I'm taking my neighbor's opioid because I'm out, or I'm taking opioids because I can't sleep. These kinds of behaviors can be a precursor that could lead into a substance use disorder, but they don't diagnose a substance use disorder on their own. It's estimated that about 8% truly become addicted to opioids when they start from a chronic pain condition. Many people look at that number and they think, see, it's a very small problem. But when I see that number, I think about the hundreds of people right now that are suffering with opioid use disorder and started it from a painful condition. It's not a small problem for them at all. It's a big problem. So I think we have to just recognize what we were taught to tell patients in the past. If you take opioids for pain, you can't become addicted. That's what I was told to tell my patients with cancer. We know that's no longer true. We know now the use of opioids, the risk for opioid use disorder does increase with that dose of opioids, and that there's other risk factors that can play a part. So your risk for becoming addicted or having a substance use disorder from taking opioids that started with a painful condition, things like genetics, psychiatric disorders, younger age, social and family environments, childhood trauma, these can all contribute. And I do wanna point out, this doesn't mean that if a person has had childhood trauma, they should not receive opioids. This has been misinterpreted, I feel. And we need to understand that everyone has a right to opioids if they're suffering and if they have pain. But these may be important factors to consider when you're initiating opioid use, making sure you're carefully monitoring that person, knowing they may have an increased risk of developing a substance use disorder and monitoring them more closely, making sure they're well-educated about what they're taking and how it can change over time to become a problem. So the thing that I think has been studied a little less and what I'm really interested in is how symptoms may contribute to this transition to opioid use disorder. And so several studies I've done have focused on people receiving methadone for opioid use disorder and trying to understand more about their symptom burden and how addressing that might improve their retention and reduce the recurrence of their substance use when they're in treatment programs, receiving medication for opioid use disorder. And I'm gonna talk about one small study that we did recently in a little more detail. We wanted to investigate the experiences of pain as it was described by adults receiving a daily methadone dose. We wanted to understand the pain management needs those people had and how it would influence their substance use. And this was really following up on a few other studies we had done in the same population that showed there was a high burden of undertreated symptoms. And by that, we saw pain, depression, anxiety, withdrawal, and sleep. And about 73% their first use of opioids was in response to a painful event. And that was a study of about 60 people here locally from the Spokane area. We had a qualitative descriptive approach to answer our primary question, how do adults in medication for opioid use disorder treatment describe their experience of pain? We had two sources of data. We had some survey data that used the pain intensity and pain interference scores. And we also did in-depth interviews to ask them to describe their withdrawal experiences. From that, we went into a secondary analysis specifically looking for their experience of pain. And we did a content analysis to identify themes. First, I'll just show you, again, this was a small sample of about eight people. On the left, you can see their pain intensity. And it was always between 4.7 to 6.5 in that moderate range of pain. So it never really got much better over a week's time. You can see that tracked on the graph. On the right, you'll see the pain interference. We just asked that at the beginning of the study and again, in about a week's time, and it didn't really budge too much. On the PROMIS scale, anything over a 50 is above the normal healthy adult for average. And these were operating at 61 to 65 in the pain interference range. So they were experiencing a fair amount of pain. The main themes that they told us about, the types of pain that they talked about, number one was withdrawal pain and chronic pain. And then they also talked about their responses to pain, their pain effects and their coping strategies. As far as the types of pain, they described pain related to opioid withdrawal. And you can see their common descriptors in the box here that they used. One said, a lot of the pain that I suffer from for my illness also seems to be symptoms of withdrawal. So when I'm feeling joint pain, I'm always thinking that that is my arthritis. It's in my hands, the fingers, my knees, my elbows. It seems like pretty standard. Like everybody seems to have problems with their joints. It's in your joints. And it's definitely related to withdrawal. The deeper your withdrawal symptoms are, the deeper the body ache goes. So there seemed to be a little bit of trouble distinguishing from whether it was withdrawal pain or their chronic pain in some cases. They also talked about chronic pain. This particular study, we didn't recruit people who had a known diagnosis of chronic pain, but they all seem to talk about chronic pain nonetheless. As one said, I got a really bad back injury, L5-S1. I originally herniated it, then I tore it and now it's degenerated. Another said, I have chronic pain, which is one of the reasons I was on the narcotics in the first place. If I don't get enough sleep, I get these raging migraines. They also talked about the response that they had to pain. They talked about sleep disruption, insomnia, interferences with mobility and financial stress all related to their pain. As one said, I seem to have a really hard time when winding down or feeling any type of relaxing. So I don't go to sleep. Another said, you wouldn't believe the amount of money involved to stay out of pain. It's going to be a lifelong thing for me. They also talked about coping strategies that they used, music, a hot shower, companionship, medication timing and distraction. As one said, when I'm working, I don't necessarily think about my aches and pains. With the medication timing, the people in this study were on a daily methadone dose and they mostly had to go to the clinic and receive that dose, but on holidays or weekends, they might receive some take-home doses. This study was taken right before we started the lockdown for the pandemic in 2020. So they would tell us about how they were using dosing scheduling of their own to help alleviate their symptoms when they didn't have to go into the clinic. So instead of taking all of their dose in the morning, they were sometimes splitting the dose and taking some in the afternoon. So that was one way they explained how they coped with their pain. They also talked about coping with their pain using substances, and you can see in the box, the substances that they reported they used. It was a variety of both legal and illegal substances to relieve their pain and other symptoms. As one said, in the past, I've tried using other drugs sometimes. If I knew someone who had Valium or something, I would ask if they could spare any, that would help. So this was a small sample in one little corner of the globe, but I do want to bring into focus how it aligns with other research. There was a large study out of France showing people receiving medications for opioid use disorder with chronic pain, 15% were not prescribed and did not self-medicate with any analgesic drugs. 52% were prescribed analgesics. Most of them, 49%, also self-medicated for pain on top of the prescribed analgesics. 32% exclusively self-medicated for pain. So in total, about 84% would fall into this category of self-medicating or trying to manage their own pain in some kind of way. Those with chronic pain had more withdrawal-related pain. They consumed significantly more street drugs, including street buprenorphine, methadone, heroin, and morphine. If we travel now to Scotland, there's a study again with about 500 people found a significantly higher proportion of medication with opioid use disorder patients with chronic pain using non-medical benzodiazepine, so not prescribed, and illicit or not prescribed cannabinoids at the study inception versus those without chronic pain. A higher proportion of those with chronic pain continued that non-medical benzodiazepine use and illicit cannabinoid use during the five-year follow-up period. So my conclusion from that is that universally, if symptoms are not addressed, patients will self-manage. And sometimes that may be healthy coping, as our participants discussed, and other times it may be more risky kinds of behaviors. So as a clinical implication, it's important to assess symptoms thoroughly and holistically. Is it chronic or acute pain they're talking about? Is it emotional and physical pain as well? Do they have spiritual distress or crisis in their life? Offer solutions to relieve their suffering. Pain self-management programs can help educate them on some different strategies. You may need to make some referrals. Certainly look at those non-pharmacological options and maybe peer support groups. Ensure those mental health needs are being met. We know anxiety, depression, PTSD often co-mingle with both substance use disorders and with pain, and the two together usually make each condition worse. We have to ask about their substance use for symptom management specifically with a focus on harm reduction. Ask if they're using cannabis, ask how they are misusing opioids, and we can't be punitive about that. We need to ask them to understand more about how they're using those symptoms to manage their pain. Methamphetamines, that's being used a lot as well for symptom management, and benzodiazepines. So important to ask and understand why those substances are being used in the context of symptoms. You can suggest medication dosing alternatives when it's appropriate. Look at the timing. If they're on a one-time dose of methadone and that is not doing it as far as helping manage their pain, maybe there's some other options. Maybe it's the type of drug, a long-acting drug might be more appropriate, adding some non-opioids. So also, we can't forget that there's that increased risk of overdose when people are self-medicating or taking opioids other than prescribed or adding things to their opioids that are going to be sedating. It's really important to know this is a possibility and to educate and provide them access to naloxone or Narcan to reverse that potential for overdose, making sure they have friends or families who have access to that drug and who can help them if they get into trouble. So I'm gonna segue now to a recent study we just wrapped up focusing on adults with chronic pain and non-pharmacological pain management decision-making. The research question I'm going to focus on here for the next few minutes was created by an honors student that worked with me here at WSU. She's now graduated, Caitlin Ware. What influences individuals' choice of non-pharmacological pain management therapies? We had an IRB approved pilot study investigating the use of complementary and integrative health options for adults prescribed opioids for chronic pain. And this was really following up from some of that work in the opioid use disorder population where they reported to us a lack of options they were given to opioids when they were being treated for their pain conditions. We wanted to better understand how to engage people in these complementary options that are known to be effective. The context for this smaller honors project was a larger pilot study funded by the Race Redeem Foundation, which is a local foundation dedicated to reducing harms of substance use. And also the Institute of Translational Health Sciences. This was in partnership with the Spokane Regional Opioid Task Force, which is a diverse group of healthcare and wellness practitioners. We've been meeting together since 2018 as the Non-Opioid Pain Management Group. Our mission is to remove barriers and increase usage of non-pharmacological pain management treatments within the Spokane area. So this parent study, the purpose was to examine the feasibility, acceptability and effectiveness of a process to remove barriers to receiving non-pharmacological pain management therapies. We wanted to encourage compassionate conversations related to opioid use reduction, determine how free access to non-drug pain options would be received. And then after we received our funding and we had all of our protocols ready to go, the pandemic hit and we had to change everything into a telehealth option. So we wanted to determine now how telehealth options would be received. Our participants had the opportunity to attend a weekly 45 minute treatment session over a six week period with two chosen providers using Zoom technology. And the modalities we had them select from were yoga, massage, chiropractic and physical therapies. We chose those because we had done a local street fair asking people out of a list of about eight or 10 different possible non-drug pain modalities, which they would be most interested in. And we went to the literature, the research supporting the modalities that we would offer. And these four came out on top. We did have wonderful partners at CHAS Health and Northwest Spine and Pain Medicine who helped us with our recruitment and our study planning. And from this, we developed a recruitment script and we were asking participants, I'd like you to consider some options that might help with your pain and function. Would you like to hear more about a study we are participating in to try some different therapies? No, we didn't say anything about reducing opioids in this conversation, in this initial recruitment script. We were looking for people who had an opioid prescription, but we didn't want them to feel that we were asking them to stop their opioids or that this would be an either or situation. And we did have some people calling and asking if they would have to stop taking their opioids in order to be in the study. And the answer to that was no. We would be happy if this helped people need fewer medicines but that wasn't the goal. We wanted to see how interested they would be in just trying some of these non-opioid modalities. So again, these are preliminary results just based on this one small research question about the decision-making process to choose one of these modalities. And you can see on the screen here, we asked them, do you have any previous experience or knowledge of this treatment? Please tell us about this past experience. What influenced your choice of this treatment? We would ask him those questions after each choice. So they chose two of the modalities and they answered this question for both of those modalities. And from those data, we did some analysis using a deductive thematic analysis. And we ended up with 17 transcripts to analyze of people who had done this initial questioning with us. We use the concepts from the bio-psycho-social-spiritual model to inform our coding process. So we went in and we categorized the data first and then we saw how it would fit into one of four pre-existing categories, biological, psychological, sociological, and spiritual. We then reviewed the categories to identify any data that might represent some new themes. So here's the demographics we ended up with. On average, an age of 60, but a range of 38 to 75. So we did have a nice range of ages. The majority, 93% were white, 75% were female, a mix of marital status that you can see here. 50% had a graduate degree and most others had at least, well, all others really had some higher education beyond high school. So we had a pretty highly educated group of people showing up for this. That could be a reflection of the requirement for technology. We did have most people not working in the study, either disabled or retired. And you'll see a split on the insurance provider that they had a small number were Medicaid or state-sponsored. Almost half, 43% did have a co-occurring mental health disorder, most often major depressive disorder or generalized anxiety disorder. 100% reported back pain as their condition. And you can see they had a host of other painful medical conditions that they reported. Of note, five or more painful conditions were reported for 56% of our folks. So these were not simple cases. They were complex people with lots of comorbidities and lots of painful conditions. On average, they were reporting their baseline pain intensity was about a six, a moderate level of pain. So when you look at what modalities they wanted to try, their first choice, the most popular was yoga therapy, 56%. And for the second choice, the most popular was physical therapy, 37%. Here you can see how many sessions they actually completed that were conducted by the practitioners. The most sessions that were completed were by the yoga therapy and the second most were physical therapy. I was actually surprised that anyone at all tried and wanted to do the massage and the chiropractic virtually because it just doesn't seem like something that would be terribly effective. But sure enough, there were 24 sessions of massage and 12 of chiropractic. The patients were very interested to see what they could learn from these practitioners. We were also impressed by the attendance. There was only one missed yoga therapy session out of 32 scheduled sessions and three missed physical therapy sessions. So the attendance overall was pretty good. The results as far as the themes we were getting from what they told us about choosing a modality, physical function, cognitions with subcategories of knowledge and beliefs and past experiences. And we did think they were able to map pretty nicely onto this bio-psycho-social-spiritual model. In physical functioning, that is defined as the ability to perform activities of daily living and movements. It encompasses desired physical improvements and restrictions due to physical limitations. Pain and movement limitations inhibited the utilization of some modalities in the opinion of the participants. One said, massage, I don't think I can do because I can't hold anything in my hands. I cannot do traditional yoga. It needs to be modified with a chair or something that would allow me to not put too much pressure on my leg. One possible improvement to their physical condition was an influence in choosing a particular modality. As one said, I'd like to strengthen other areas like the core, achieve better balance. The idea of being able to increase my range of motion, especially in my legs appeals to me. Cognitions was defined as acquiring knowledge, understanding and viewpoints through thought, experience and senses. And the subcategories, knowledge, understanding of the modality and information acquired and beliefs, the use of health and how the modality will impact wellbeing, including spiritual aspects, wants and desires. So under the knowledge category, participants were more inclined to choose a modality that they had an understanding of and one supported with evidence. As one said, I think it's been around for a long, long time. It has a lot of factual evidence that proves it can work, lowers your pulse, respirations. That was in response to a choice of yoga. Another said, easy to onboard with practitioner because of understanding, we speak the language. This was a participant who actually had taught and given massage in the past and was choosing the massage therapy. So under the subcategory of beliefs, logical or spiritual beliefs had an influence on the modality choice, both negatively and positively. As one said, I believe all of these things can be achieved with yoga. Also the spiritual sense, calm the senses, a form of meditation. Another said the body-mind connection, learning how to stretch. It helped keep my athlete's body in shape. The strength of their beliefs and desires was also expressed as the degree of certainty of the reasons behind their decisions. For example, one said exercise always is a good thing. Some aspects are probably derived from yoga, stretching, awareness. I've always wanted to know more about it. They talked about their prior exposure to a modality and how that would result in either a positive or a negative view of that choice. Positive past exposure, including good connection with a practitioner, limited adverse effects and lasting relief led to the participant choosing that modality. One said I used to get a massage through the VA six per day, deep Swedish style. A negative exposure such as temporary relief, adverse effects or perceived incompetence of the practitioner found participants less inclined to choose that modality. One said I've had good results with the small amount of massage I've had. My limited experience of chiropractic was negative, so I wouldn't choose that. As I mentioned, COVID-19 did complicate things. We had to modify our recruitment and protocol. Our clinical partners have a lot of priorities to juggle. So we were just thankful that we were able to accomplish anything at all with this study. There were barriers in the beginning, the perceptions from both the participants, our providers and our practitioners that they could really do anything using telehealth that would be effective. There were obviously some technological skills required to engage in telehealth. So we had to have that figured out ahead of time and just the access and interest of the population. We did feel there was some convenience and efficiency in doing this telehealth version. We didn't have to have a specific time and place to meet with the participants. And we were able to reach a larger population. We actually recruited throughout all of Washington State instead of just narrowly focusing on the Spokane area where we started our recruitment. One said it's been difficult if not impossible to do yoga in a class, illustrating the barrier of the pandemic as well as location when searching for treatment options. A larger sample would provide us with a more diverse perspective. We had a lack of diversity in race and ethnicity. Certainly we did not fully represent the chronic pain population. We had a highly educated bunch of people. But the themes were very consistent and they were theoretically based. We had excellent attendance. We still are calculating if there were any positive effects that we could measure on our quantitative data collection. And the results do align with prior research that shows that one's philosophy of illness and healthcare influences those decisions about other modalities. So you might think about what questions you could ask a person as they're considering some non-opioid options for pain management. And this would work in any population, I think, not just the chronic pain or opioid use disorder population, but anytime. You could ask if they have any concerns about participating in this treatment, helping you get at what some of those physical limitations they may be worried about could be. What do you know or believe about this treatment? Do they have some existing barriers and knowledge or misconceptions or just some beliefs that doesn't align with their belief system? And is there any information that might help with that? Do you have any past experience with this treatment you could ask? And understand more about what was beneficial. We heard from some who indeed did have past experience and were just not using the modality because they couldn't afford it. So that's important to recognize too. There are barriers in the clinical setting that we really need to work on in order to get these options integrated. There's a lack of standardization in the treatment dose and knowing exactly what kind of modality to send a person to. There's lots of variation in the training and credentialing. I was so impressed with our yoga therapists. They had lots of experience working specifically with people with chronic pain and even had some additional training and certification in trauma-informed yoga, which I didn't even know there was such a thing. So it was really impressive to see what they've been doing to help this population. The costs definitely can be a barrier. I think it's important to look to the community and try to build some community partners. Look at your local resources, offer those in-house sessions when you can. I know our partners at the pain clinic have a yoga course now that they offer for their patients. They're at a very low cost. And I think having those kinds of things to offer people who are showing up for care is a wonderful advancement. We may have difficulty advancing the research because of these small effect size, placebo effects and difficulty blinding, but that doesn't mean we should toss out these modalities that may be helpful. The risks may be underreported. There could be more than what we realize. They appear overall to be minimal and less than some traditional medicine and surgical approaches. So it's another vote for trying the complementary care before you go to more invasive, expensive options. So for this population, the non-pharmacological modality selection was influenced by perceived physical functioning limitations, beliefs and knowledge on potential benefits, acquired knowledge and understanding from previous positive or negative experiences. We need to help broaden the perceptions and receptivities to these treatment options, provide education and resources in an open shared decision-making discussion and follow therapeutic communication guidelines, establishing trust and empathy and exchanging ideas without judgment or perpetuating stigma around the use of opioids and chronic pain. That holistic approach is important and creating a positive pain management environment. We need to reflect on our own preconceived notions and biases before we set out to help others. The CDC has a really nice guide for effective communication for people with chronic pain. I'll just refer you to that here. I won't read this all for you. Do remember to empathize, that's important. I've listed here some non-pharmacological options that do have support in the research literature just to show you there's a lot to choose from and they have multiple mechanisms of relief of pain. So again, choosing more than one item is usually gonna be needed to have the best results and is probably a good strategy. I wanna end with just a call to action. My partners at the American Society for Pain Management Nursing and colleagues at the International Nurses Society on Addiction have created some practice recommendations looking at pain management and risks associated with substance use. The bottom line is we need safe and effective pain management regardless of substance use risk or history and an integrated holistic and individualized approach. The AMA agrees and also has a call to action about rescinding arbitrary laws and policies, looking at how health insurance companies pay for some of these options and emphasizing social determinants of health. I wanna thank you all who have listened today, really appreciate you being here and I have a slew of collaborators and hardworking people that have helped with this project on the screen but right now I'd love to hear any questions you may have. Thank you. Thank you, Marianne, for a wonderful presentation. We have some time for questions if you haven't put your question in, there's still some time to do that. I'm going to start with some of the questions that have come forward. One person asked if a payer was to develop a program for folks with chronic pain to encourage the non-pharmacological treatment, what services would you recommend to include? I think number one, that yoga and physical therapy are things that there is lots of literature out there showing support for those but yet they're not always available, not always covered enough and not thought of. Yoga is not considered a medical treatment so it's not something people think of. So I'd probably would start with those but of course the massage and the chiropractic also may have their benefits but if I had to pick off the top, people really seem receptive to yoga and physical therapy so we could just start there even and probably make some strides. Thank you. Yes, that sounds good. I agree with that. Did you ever consider medical hypnosis as an option for the patients? And if not, why not? Ah, I'm glad somebody mentioned that because I don't know if I have that on my slides but there is evidence out there that can be helpful. So I certainly would include that if someone wanted to try to integrate that into their practice, do a small pilot, see if it helps some folks. If they think it helps, let's make it available. Yeah, and a person had asked, they thought you mentioned this but they didn't catch it. How did the participants access the non-pharmacological interventions? Because of COVID, we had to do this all using telehealth consultations. So it was really a transfer of information. We did ask that they had a camera so we could see them do some of the exercises, repeat some of the things they might've learned but all we were able to do for this study was telehealth. Okay, so a lot of it was information but it's amazing. I did during the pandemic myself some physical therapy during telehealth and I actually was able to do a lot more than I thought I was able to do. So yeah, I guess when you're creative, creativity is the mother of invention here. Well, and I will tell you, that's what I was most impressed about with our practitioners. For example, the massage, I really didn't know how they were going to deliver their massage but they were able to share techniques using various household objects and have a demonstration and then have the participants show them back what they were doing. And they had some good results as far as the patient's participation, their perspectives, what they shared with us. We don't have good measurements as I said yet calculated but at least from their verbal perspectives, they thought it was helpful. Mm-hmm. Here's another person asked, if you have any experience with chronic pain patients usually utilizing pain reprocessing therapy? There is some really great research that's coming out. I think I know what they're talking about because there was a headline story in the newspapers just a couple of months ago. This all ties back to where do we process pain? We process it in the brain. So the reprocessing is about helping to change that message pathway, reprocess that pain message and there's really good evidence. I would strongly encourage people to look into that more because the research that's out looks very encouraging. Another person asked, what would you particularly recommend for somebody who had the chronic pain with the insomnia of these methods? Ah, great question. You know, obviously massage can be really soothing. Yoga, a lot of times there's types of yoga that are very relaxing to do at the end of the day. So if I had to pick two right off the top, I would say the massage and the yoga are likely to be nice end of the day relaxation, letting go of your worries. The yoga therapists were really good about helping people understand that connection with the breath and how we can slow down and relax our nervous system with deep breathing. So doing that before bedtime can be fantastic. And something you didn't mention that somebody is asking about is the Tai Chi, which there's also numbers of studies for using that. Absolutely. As a modality. That might be on one of my busy slides. Whenever I say yoga, I always should say yoga and Tai Chi because they both actually have very similar mechanisms of action likely, and they both are very effective and lots of literature research support for those Tai Chi and yoga. And this is an interesting one that someone said for underserved patients, they tend to look at YouTube videos. And do you have any particular websites that you have found that you would recommend? There's some fantastic ones out there, really. Yes, there's Sarah Beth is a great YouTube. Adrian has a very large practice. There's wonderful yoga videos out there. And there's probably many that I haven't come across. And I think that's a wonderful way to get something inexpensive, accessible to all. And here's a comment from somebody that you should definitely hear. This is a very relevant presentation to my work and working with patients with chronic pain, alcohol and substance use treatment program, especially during COVID, where patients do tend to self-medicate. So that's a big thank you for your work. Thank you for the comment. Yeah, yeah. Did you have any people that weren't willing to try the complementary therapy? Well, yes, all the people did not join this study. And we'll have that in a formal research manuscript, hopefully coming out before long. You know, I think we had maybe 30 people that were referred to us and maybe 10 or so. As soon as they realized it was telehealth, they weren't interested. So some people had a misunderstanding that it was going to be in person. So definitely, it's a hard sell that this would be helpful. I certainly don't think it's better than in person, but in a crisis, I think it's better than nothing, certainly. And it was relatively easy to do without a space and a place. Well, and I think this question kind of focused on the people not willing to try a complementary thing, even when it is offered in person. And I think what you had is those questions that you had about, you know, what experiences they've had in the past or what they've heard, or, you know, if they've had a negative experience that might be, or if they've never heard of it, it might also be another thing. Exactly. My theory is I always, the first answer to most innovation is usually no and why it's not a good idea. And we have to be patient and give people a chance to work through their fears or their misgivings and just be patient. Well, thank you. We are really out of time. I thank you so much for your presentation on this webinar. And just as a reminder to the participants, we are able to provide nursing continuing education for this session. At the end of the webinar, you'll get an email with an evaluation form from ASPMN. You must complete this evaluation within 10 business days in order to receive your CE certificates. And a link to retrieve your certificate will be on the thank you page after you complete the evaluation. And even if you are not applying for continuing education, please take a few moments to assess the evaluation and provide your feedback from today's session. I also wanted to let you know that because this is funded by PCSS, you'll receive a second evaluation from that. And please complete that second evaluation also. That provides information about the grant and the offerings that we are giving and what effect they're having. And a reminder that today's webinar was recorded and will be posted tomorrow afternoon on the ASPMN website and on the website for Physicians Clinical Support System in the near future. That URL is PCSSNOW.org. And a calendar of upcoming events and helpful clinical resources are available there as well. ASPMN will be giving a couple of more sessions for these webinars in the near future. And I thank you again, and we hope that you will join us for upcoming sessions.

opioid therapies

pain management

chronic pain

ASPMN

Prescribers Clinical Support System

opioid use disorder

non-pharmacological pain management

healthcare workers

substance use disorders

integrated multidimensional approach