3033336_Non-Opioid_Pain_Intervention_for_Veterans

1 Non-Opioid Pain Intervention for Veterans Your Name Here Antioch University Santa Barbara Course Name & Number Instructor Due Date

2 Table of Contents Abstract ............................................................................................................................................ 3 Objectives .................................................................................................................................... 3 Methods ....................................................................................................................................... 3 Results .......................................................................................................................................... 3 Conclusion ................................................................................................................................... 3 Background ...................................................................................................................................... 4 Problem ............................................................................................................................................ 5 Clinical Questions ............................................................................................................................ 7 PICO Questions ............................................................................................................................... 7 Population .................................................................................................................................... 8 Intervention .................................................................................................................................. 8 Comparison .................................................................................................................................. 8 Outcome ....................................................................................................................................... 8 Specific Aims ................................................................................................................................... 8 Methods ........................................................................................................................................... 8 Review of the Literature .................................................................................................................. 9 Overview ...................................................................................................................................... 9 Histopahthology of Opioid Addicition ...................................................................................... 10 Opioid And Non-Opioid Use In Pain Management ................................................................... 10 Non-Opioid Interventions .......................................................................................................... 11 Effectiveness Of Non-Pharmacological Interventions .............................................................. 12 Summary and Conclusions ............................................................................................................ 13 References ...................................................................................................................................... 15

4 Abstract Objectives Opioid addiction is increasingly affecting the strategies enacted to manage chronic pain among veterans effectively. The use of alternative non-opioid interventions has been discussed in this paper, with its effectiveness being more operative to veterans. In this case, non-opioid modalities have an increased long-run benefit and are more effective in managing chronic pain among veterans. Methods This paper follows a systematic review of 20 research articles from reputable sources to discuss the effectiveness of non-opioid modalities in pain management among veterans and the risks associated with opioid use for the same purpose. Results The use of non-opioid modalities for pain management has been associated with increased effectiveness in pain management among veterans in the United States. Findings link its use to reduced opioid addiction and enhanced pain management. Conclusion In the increased effectiveness of non-opioid modalities for pain management among veterans, this paper concludes by indicating the risks of opioids for the same purpose. As a result of the increased risks associated with opioids, non-opioid modalities have been recommended for chronic pain management. Keywords: Opioids, non-opioids, veterans, chronic pain

5 Non-Opioid Pain Intervention for Veterans Background The increasing reliance on opioids for pain medication has increased the overall drug overdose in the United States. Currently, veterans endure chronic pain from the battle and through musculoskeletal injuries. In this case, drug-related overdose among veterans in the United States increased in the past 15 years due to opioid use (Hsu et al., 2019). Opioids may effectively reduce the musculoskeletal pain that veterans may suffer as a result of injuries but may cause an addiction. It may be understood that veterans' chronic pain may not be easily managed permanently. Therefore, the easily-available opioid prescriptions may guide the effectiveness of its interventions while causing an addiction problem. An increasing body of evidence points towards the harms of opioid treatment and limited long-term benefits of its use, leading to the emphasis on non-opioid interventions (Frank et al., 2019). Non-opioid interventions are increasingly gaining popularity as a result of their long-term effectiveness in chronic pain management. Non-opioid interventions may include various initiatives such as specific physical exercises, non-opioid medications, and placebo. These initiatives have presented a high chance of success in pain management among veterans to emphasize its use in the current pain management techniques. While opioids may negatively impact the patient's health in the long run, it is essential to understand what causes an increased reliance on this intervention for veterans. Pain is the leading source of increased reliance on opioids among all Americans ( Pain Management , n.d.). In essence, musculoskeletal pain accounts for most of the veteran's need for opioid pain medications. From a hypothetical perspective, musculoskeletal pain from injuries may be unbearable to the veterans, leading to interventions to reduce this outcome. There are various

7 pain management develop an opioid disorder primarily associated with opioid addiction. Therefore, the opioid abuse crisis can be dependent on the time engaged in its use; the longer one engages in opioid use, the more the chances of developing an addiction or abuse of heroin and other substances. Current interventions may restrict the increase in opioid dependence yet enhance the chances of secondary effects of its use. Various policies have been enacted in the United States to tame the opioid crisis, which has not been effective. In this case, the introduction of PDMP enhances the reduction of opioid misuse (Lee et al., 2021). This is the primary expectation of introducing this policy to manage chronic pain for veterans and other Americans. With this policy, prescribers may review the patient's prescription history before recommending an additional dosage of opioids. Research indicates that this policy leads to a decreased use of medically prescribed opioids yet increases the use of heroin as an alternative (Lee et al., 2021). In addition to policies, stigma is another factor enhancing the opioid crisis in the United States. Tsai and colleagues (2019) indicate that stigma against opioid reliance exasperates the opioid crisis. In this case, stigma enhances withdrawal from substantive healthcare services. Increased withdrawal from proper medical care leads to increased opioid mortality. In this case, relying on opioids for pain management enhances the stigmatization of those using this technique. Therefore, this may reduce their chances of seeking appropriate medical attention. The relevance of this problem for a nurse anesthetist is centered on their role in managing opioid use. Research indicates that nurse anesthetists are responsible for regulating opioid use for pain management in healthcare (Edwards et al., 2020). In this case, if opioids must be regulated for pain management among veterans, nurse anesthetists must be at the forefront of this initiative. Patients rarely have control of what is being prescribed to them. It is the role of the

8 nurses to observe and mitigate the risks associated with potential opioid misuse through effective prescriptions that would reduce the chances of opioid abuse. Nurse anesthetists can therefore guide the implementation of alternative techniques to manage opioid misuse through the gradual decrease in its use. There are many alternatives to opioid pain management techniques. Nurse anesthetists may further prescribe these alternatives to reduce the reliance on opioids on veteran chronic pain management. Therefore, nurses are central pieces in the implementation of opioids for pain management among all patients. The problem addressed in this paper may guide their understanding of the dangers surrounding opioid misuse and the long-term advantages of recommending non-opioid interventions. Clinical Questions The paper's relevance is to address the clinical significance of using non-opioid interventions for pain management and its long-term benefits as opposed to opioid use. While opioids have been used to critically manage pain in the short term, their ineffectiveness has introduced the need to have a more effective method to manage pain among veterans. Therefore, the clinical question in this paper is given as the hypothesis: Non-opioid interventions for pain management among veterans are effective in the long run compared to opioid modalities. This hypothesis will guide the comprehension of the fundamental clinical question that is being addressed in this paper. PICO Questions The PICO questions for this paper are indicated in the following bullets as adapted from the hypothesis above

10 articles to increase the credibility of their findings before the investigation. In addition to this, credibility was further determined by the author's credentials in selected articles and cited references. In this case, the author's experience in medical research or practice was fundamental to the selection of these articles. For articles without an author, its affiliation with reputable medical sources was the preferred criteria. The search strategy for the articles involved an effective selection of those matching the established criteria of relevant articles for the research. This established criterion considered the selection of specific keywords cogitated as necessary to this research. In this case, most of these keywords were obtained from the hypothesis and the PICO questions to effectively guide the selection of appropriate materials contributing to its intended outcome. Therefore, the search involved Boolean operators and keywords in selecting the most relevant articles. These keywords include "opioids" and "non-opioids" and "veterans" and "pain." These keywords enhanced the selection of materials that investigated questions related to the aim of this research. In addition to this, the articles matching this criterion were further screened for keywords in their abstracts. It was a requirement that the articles containing an abstract have at least three of the keywords, with "pain" being a mandatory keyword. For those without an abstract, these keywords were screened through searching the document for their presence. Review of the Literature Overview The use of opioids for chronic pain management has been widely adopted for veterans' musculoskeletal injuries. Veterans are the most affected population in chronic pain in the musculoskeletal area and other areas because of the intensity of challenges they endure in their field of service. While opioids effectively reduce the pain experienced by these veterans on a short-term basis, they may cause more harm in the long run. Therefore, many researchers

11 advocate for non-opioid modalities for improved pain management. They have a long-term and more effective solution to pain management among veterans and other population groups experiencing chronic pain. Histopathology of Opioid Addiction Opioid addiction has been a fundamental problem in the United States since its introduction. According to the National Institute on Drug Abuse (2021), the distribution of opioids increased in the US in 1990 due to its increased demand. This led to a negative outcome where nonmedically distributed opioids further increased in the same year, as Phillips et al. (2017) indicate. This shows that the US's increased use of opioids for pain management led to its abuse through nonmedical distributions. Research attributes stigma as a fundamental cause of opioid abuse (Tsai et al., 2019). In this case, stigmatization of those using opioids for pain management causes their alternative seeking pain management techniques. While this is true, the education level is further inversely correlated to opioid addiction and considering non- pharmacological approaches to pain management (Edmond et al., 2018). Therefore, the opioid addiction crisis can be attributed to sociological factors, which may be averted when non-opioid alternatives are integrated into the pain management modalities among veterans in the United States. Opioid And Non-Opioid Use In Pain Management In the occurrence of chronic pain among veterans, both opioid and non-opioid modalities are effectively managed. However, research indicates that non-opioid use for pain management is more effective than antagonist opioid modalities (Krebs et al., 2018). There is an antagonistic relationship between opioids and non-opioids in pain management. Krebs et al. (2018) further indicate that the pain management in non-opioid patients in their research study was more

13 Non-opioid pharmacological interventions may be as effective as opioid interventions yet enhance adverse events resulting from withdrawal from treatment (McDonagh et al., 2020). The effects of opioid interventions on addiction and misuse have initiated the opioid pandemic that is currently present in the United States. Research indicates that the complex social, psychological, and biological factors enhance this outcome (Lee et al., 2021). This complexity can be further observed in the use of non-opioid pharmacological interventions (McDonagh et al., 2020). These interventions include medication that can help manage pain in veterans yet do not involve opioid modalities. However, while the effectiveness of this method may be apparent, the non-opioid non-pharmacological alternatives may be further effective in enhancing pain management among veterans. Effectiveness Of Non-Pharmacological Interventions The non-pharmacological alternatives to pain medication may have enhanced effectiveness when it comes to chronic pain management. In this case, research suggests that this alternative may enhance a long-term benefit in pain management (Kaye et al., 2020; Skelly et al., 2018). In addition to this, Voll et al. (2021) indicate that considering a biopsychosocial approach to managing pain has been effective in pain management and an overall reliance of morphine equivalent daily dose by up to 21 mg. To support these non-pharmacological alternatives, the Veterans Health Association has recommended implementing multi-systems level programs for chronic pain management (Frank et al., 2019). These systems include physical exercises and therapy. In addition to this, Molloy et al. (2020) suggest that there has been an overall decrease in musculoskeletal injury pain among veterans who undertake physical exercises as a pain management technique.

14 The high effectiveness of non-opioid modalities for pain management further considers modern pain management among veterans in the United States. Findings from the perioperative questionnaire assessment indicate that 82 percent of patients involved in non-opioid pain management modality were satisfied and had effective ways to manage pain (Alter & Ilyas, 2017).In addition, research indicates the high effectiveness of non-pharmacological interventions in reducing the overall dependence on opioids (Daniels et al., 2019; Kaye et al., 2018). While this effect is apparent, nurse anesthetics play a central role in enhancing this outcome. According to Edwards et al. (2020), the fundamental role of certified registered nurse anesthetists involves educating and supporting veterans against the misuse of opioids through recommending and prescribing non-opioid alternatives. This strategy enhances the effectiveness of non-opioid modalities in the management of chronic pain among veterans. Summary and Conclusions The increased effectiveness of non-opioid interventions for pain management in the United States among veterans has more long-run benefits than its opioid alternatives. The findings of this paper indicate that non-opioid alternatives are more effective compared to opioid modalities in chronic pain management. In this case, the risks associated with using opioid modalities in chronic pain management are more severe. Opioids have been linked to increased abuse and addiction, which prolongs their use without long-run effectiveness in pain management. On the other hand, non-opioid pain management has long-run effectiveness in pain management among veterans. As BMI and other diseases are associated with accelerated musculoskeletal injuries and pain, implementing non-opioid pharmacological and non-opioid non-pharmacological interventions may guide treating veterans with chronic pain. Opioid

16 References Alter, T. H., & Ilyas, A. M. (2017). A Prospective Randomized Study Analyzing Preoperative Opioid Counseling in Pain Management After Carpal Tunnel Release Surgery. The Journal of Hand Surgery , 42 (10), 810–815. https://doi.org/10.1016/j.jhsa.2017.07.003 Azadfard, M., Huecker, M. R., & Leaming, J. M. (2021). Opioid Addiction. In StatPearls . StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK448203/ Carey, E. P., Nolan, C., Kerns, R. D., Ho, P. M., & Frank, J. W. (2018). Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent Initiation of Long-Term Opioid Therapy. Journal of General Internal Medicine , 33 (1), 38–45. https://doi.org/10.1007/s11606-018-4324-y Daniels, S. D., Garvey, K. D., Collins, J. E., & Matzkin, E. G. (2019). Patient Satisfaction With Nonopioid Pain Management Following Arthroscopic Partial Meniscectomy and/or Chondroplasty. Arthroscopy: The Journal of Arthroscopic & Related Surgery , 35 (6), 1641–1647. https://doi.org/10.1016/j.arthro.2019.03.028 Edmond, S. N., Becker, W. C., Driscoll, M. A., Decker, S. E., Higgins, D. M., Mattocks, K. M., Kerns, R. D., & Haskell, S. G. (2018). Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey. Journal of General Internal Medicine , 33 (Suppl 1), 54–60. https://doi.org/10.1007/s11606-018-4322-0 Edwards, J. M., Dollar, S. D., Young, T., & Brockopp, D. (2020). The Role of a Certified Registered Nurse Anesthetist Led Acute Pain Service in Preventing Persistent Postoperative Opioid Use. The Journal of Nursing Administration , 50 (4), 198–202. https://doi.org/10.1097/NNA.0000000000000868

17 Frank, J. W., Carey, E., Nolan, C., Kerns, R. D., Sandbrink, F., Gallagher, R., & Ho, P. M. (2019). Increased Nonopioid Chronic Pain Treatment in the Veterans Health Administration, 2010–2016. Pain Medicine , 20 (5), 869–877. https://doi.org/10.1093/pm/pny149 Higgins, D. M., Buta, E., Heapy, A. A., Driscoll, M. A., Kerns, R. D., Masheb, R., Becker, W. C., Hausmann, L. R. M., Bair, M. J., Wandner, L., Janke, E. A., Brandt, C. A., & Goulet, J. L. (2020). The Relationship Between Body Mass Index and Pain Intensity Among Veterans with Musculoskeletal Disorders: Findings from the MSD Cohort Study. Pain Medicine (Malden, Mass.) , 21 (10), 2563–2572. https://doi.org/10.1093/pm/pnaa043 Hsu, J. R., Mir, H., Wally, M. K., Seymour, R. B., & Force, the O. T. A. M. P. T. (2019). Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. Journal of Orthopaedic Trauma , 33 (5), e158. https://doi.org/10.1097/BOT.0000000000001430 Kaye, A. D., Cornett, E. M., Hart, B., Patil, S., Pham, A., Spalitta, M., & Mancuso, K. F. (2018). Novel pharmacological non-opioid therapies in chronic pain. Current Pain and Headache Reports , 22 (4), 31. https://doi.org/10.1007/s11916-018-0674-8 Kaye, A. D., Granier, A. L., Garcia, A. J., Carlson, S. F., Fuller, M. C., Haroldson, A. R., White, S. W., Krueger, O. L., Novitch, M. B., & Cornett, E. M. (2020). Non-Opioid Perioperative Pain Strategies for the Clinician: A Narrative Review. Pain and Therapy , 9 (1), 25–39. https://doi.org/10.1007/s40122-019-00146-3 Krebs, E. E., Gravely, A., Nugent, S., Jensen, A. C., DeRonne, B., Goldsmith, E. S., Kroenke, K., Bair, M. J., & Noorbaloochi, S. (2018). Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis

19 Individual Benefits and Risks of Prescription Opioid Use . National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK458661/ Skelly, A. C., Chou, R., Dettori, J. R., Turner, J. A., Friedly, J. L., Rundell, S. D., Fu, R., Brodt, E. D., Wasson, N., Winter, C., & Ferguson, A. J. R. (2018). Non-invasive Non- pharmacological Treatment for Chronic Pain: A Systematic Review . Agency for Healthcare Research and Quality (US). http://www.ncbi.nlm.nih.gov/books/NBK519953/ Tsai, A. C., Kiang, M. V., Barnett, M. L., Beletsky, L., Keyes, K. M., McGinty, E. E., Smith, L. R., Strathdee, S. A., Wakeman, S. E., & Venkataramani, A. S. (2019). Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLOS Medicine , 16 (11), e1002969. https://doi.org/10.1371/journal.pmed.1002969 Voll, P., Brooks, A., Vartan, C. M., & DiScala, S. (2021). Pharmacist interventions in an outpatient pain clinic at a Veterans Affairs Medical Center. Journal of the American College of Clinical Pharmacy . https://doi.org/10.1002/jac5.1548