July 16, 2014
News Review From Harvard Medical School -- 'Telecare' May Improve Pain Management
An automated program to monitor symptoms may improve pain treatment more than typical care, a study suggests. The study included 250 people who had long-term muscle or joint pain. They were randomly divided into 2 groups. One group was asked to report symptoms and answer other questions at regular intervals. This was the "telecare" group. People filed their reports using an automated telephone or Internet system. Based on this information, a nurse called from time to time with adjustments to the treatment plan. Doctors changed prescriptions and doses according to a set of rules based on research. The other group received usual care from their primary care doctors. After a year, more than half of the telecare group and one-quarter of the usual-care group reported at least a 30% improvement in pain levels. About 19% of the telecare group and 36% of the usual-care group reported that pain got worse. About three-quarters of the telecare group said their medicines were good to excellent. Half of those in the usual-care group described their medicines this way. The Journal of the American Medical Association published the study. HealthDay News wrote about it July 15.
By Robert H. Shmerling, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
As unpleasant as pain may be, it usually serves a useful purpose: it warns you of danger.
If you touch a hot stove or sprain your ankle, the pain tells you to move your hand away from the stove or to rest your ankle. For this sudden type of pain, the discomfort subsides once the problem has passed or is treated.
But, for millions of people, pain is long lasting (chronic). Examples include back pain, headaches and arthritis pain. In these cases, chronic pain serves no useful purpose. Unfortunately, chronic pain often has an unknown cause and is difficult to cure. That's why doctors often resort to trial and error, trying one treatment (or combination of treatments) after another.
A new study takes a fresh approach to treating chronic pain. The Journal of the American Medical Association published the study.
Researchers enrolled 250 people with chronic pain. Most had had poorly controlled pain for many years. They were randomly assigned to two groups. One group received "telecare." They got automated, symptom-based advice by telephone or Internet according to a standard algorithm. A nurse and doctor supervised the program. The other group received "usual care" from their primary care doctors.
Those assigned to receive telecare had:
- Better pain control -- After one year, about half reported a 30% reduction in pain. This was nearly double the rate of the usual-care group.
- A lower rate of worsening pain -- After 6 months, only 19% reported worsening of pain. This was about half the rate of those in the usual-care group.
- Better overall pain treatment -- Almost three-quarters reported good-to-excellent pain control, compared with half of those in the usual-care group.
Another finding deserves particular attention: few people in either group were started on opiates (narcotics). These are the most powerful -- and most commonly abused -- pain medicines.
These findings suggest that automated telephone or Internet-based communication can guide pain treatment effectively. In fact, it may be better than the standard ways doctors treat pain during office visits.
Chronic pain is among the most common and vexing problems for which patients see doctors. This study could be among the first to signal a major change in how pain is managed. It could be particularly important for people who have difficulty getting to their doctors' offices and for places with few doctors.
What Changes Can I Make Now?
If you have unexplained pain, the first step is to see your doctor. If a specific cause can be found, a specific treatment (such as a medicine or surgery) may cure the condition.
But, even when there's no cure, some simple steps may help you get more comfortable. For example:
- Stretching or a heating pad can be an effective treatment for back pain. This works especially well for pain caused by muscle strain or spasm.
- A wrist brace can lessen pain from tendon inflammation (tendonitis).
- A change in your exercise routine can make a big difference. A physical therapist or personal trainer can provide guidance.
There are many other options for treating chronic pain, including:
- Relaxation exercises
- Electrical stimulation (using a transcutaneous electrical nerve stimulator, or TENS)
- Chiropractic care
- Application of cold (especially just after exercise)
New medicines and a better understanding of how to use them have provided pain sufferers with more options than ever before. Your doctor may recommend one or more of these medicines:
- Over-the-counter pain relievers (such as acetaminophen)
- Pain relievers applied to the skin (such as BenGay or capsaicin)
- Anti-inflammatory drugs (such as ibuprofen)
- Muscle relaxants (such as cyclobenzaprine)
- Antidepressants (such as duloxetine)
- Anticonvulsants (such as gabapentin)
- Narcotic-like pain relievers (such as tramadol)
- Narcotics (such as codeine)
Pain can also be treated with injected medicines. Nerve blocks and corticosteroid injections are examples.
All drugs can cause side effects, so be sure you know what to watch out for. Report potential side effects to your doctor.
If you take a medicine for pain, take the lowest effective dose. The lower the dose, the fewer and less severe the side effects. If your pain varies in a predictable pattern, it's often better to "stay ahead" of chronic pain. To do this, you would take your medicine at regular times, rather than waiting until you can't bear the pain.
As this new research shows, a well-designed protocol that adjusts the choice and dose of medicines based on symptoms can help reduce even pain that has been present for years.
What Can I Expect Looking to the Future?
It's not always possible to stop pain. However, researchers are busy developing new treatments and, as in this new research, new ways of adjusting them.
Pain is likely to remain a common reason that people seek evaluation and treatment from their doctors. But I hope that in the future we'll see less chronic pain and better pain control. Advice delivered by phone or the Internet could play a major role.