432 - Reframing Pain, Presbyopia Drops, Making Room for Recovery

From the Literature

1)    Reframing Chronic Pain Through Pain Reprocessing Therapy

One of the major functions of pain in our bodies is to warn us that something unhealthy is happening. Just like other processes in our body – immune reactions for instance – sometimes our pain system goes out of control and is not helpful any longer as a warning system. To combat both chronic pain and its emotional toll, counseling is recommended, specifically cognitive behavioral therapy (CBT), biofeedback, distraction therapy, problem solving therapy, and mindfulness training.

Pain reprocessing therapy (PRT) is a new modality developed by the authors of a study in JAMA Psychiatry. As described by the authors, PRT “emphasizes that the brain actively constructs primary chronic pain in the absence of tissue damage and that reappraising the causes and threat value of pain can reduce or eliminate it.” It incorporates some proven therapies for pain – exposure therapy, mindfulness, etc. – as well as cognitive behavioral therapy for anxiety. The PRT intervention consisted of a telemedicine visit followed by eight 1-hour counseling sessions over 4 weeks.

The authors of this study randomized 150 patients with chronic (~ 10 years average) back pain to PRT vs. usual care vs. “open-label placebo” added to usual care. [Open- label placebo is an intervention that takes advantage of the significant placebo effect that can occur in intervention trials. Subjects are given a placebo, in this case a saline injection into the region of pain, under full disclosure that they are not getting an active medication.] The authors measured different pain scores monthly after the start of therapy, administered several psychiatric function, behavioral health, and pain belief scales, and even tested responses to evoked and spontaneous pain while the subjects were undergoing functional MRI (fMRI) studies to make the case for actual change in brain function due to the therapy.

PRT statistically significantly reduced all the pain outcomes measured through 12 months. The effect sizes for these changes were considered “large.” The proportion of PRT patients who reported being in “no pain” or “nearly no pain” was 66% immediately post-treatment (vs. 20% and 10% in placebo and usual care groups, respectively) and 52% (vs. 27% and 16%) at one year. The least favorable number needed to treat to achieve “nearly no pain” at one year would be ~ 4. It is also reassuring to see all the pain measures respond equivalently and to see the disability and affective measures respond significantly in the same direction. Both evoked pain and spontaneous pain episodes were reduced in intensity. Finally, the authors performed a “mediation analysis” that demonstrated that the reduction in pain was correlated to changes in scale measuring the belief that their pain was due to injury and fear of movement.

John’s Comments:

I have encountered the idea of helping patients “reframe” their chronic pain before, but

this is the first study I’ve seen that targets this specific idea as an intervention. I reached out to Dr. Robert McNamara, PhD, a licensed clinical psychologist at Carilion Clinic and Assistant Professor of Psychiatry and Behavioral Medicine at VTCSOM who specializes in the assessment and psychotherapy for patients with chronic pain and/or chronic medical conditions. He writes:

“This treatment modality, packaged as such, is relatively new and there is not significant literature on the topic. However, from what I can gather about PRT, it appears to be a conglomerate of some very sound, well-established psychological treatments for pain – CBT, exposure therapy, and acceptance and commitment therapy. With that said, I am not aware of anyone practicing PRT in the community…

One of the most important aspects of this study is a limitation: “The study sample was relatively well educated and active and reported long-standing low to moderate pain and disability at baseline.” I am particularly curious about whether these back pain patients had comorbid psychiatric conditions, such as major depressive disorder, post-traumatic stress disorder, and/or anxiety disorders, which often co-occur with chronic pain. The symptoms of these disorders can complicate the cognitive work necessary to intervene with beliefs about pain - especially if the pain is sequela of trauma. As they mention, education and activity levels – and levels of debility – are important factors to consider related to generalizability. I would be attentive to all of the above-mentioned demographic considerations when developing expectations about the efficacy of PRT with a broad range of patients. But, based on their results and the techniques they have used to develop PRT, I would definitely support its use in practice!”

Reference:

Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. 2022;79(1):1. Link

News from the Pharm and a Question From a Patient

2)    Pilocarpine 1.25% (Vuity) in Place of Reading Glasses?

Question:

“I’ve heard about some new eye drops I can use instead of using my reading glasses. Can you prescribe it for me?”

Answer:

Pilocarpine drops have historically been used multiple times a day to treat the elevated intra-ocular pressure in glaucoma at a 1%-4% concentration. These drops have recently marketed under the name Vuity in a 1.25% concentration to correct age-related presbyopia (blurred or difficulty seeing close-up) as an alternative to reading glasses through pupillary constriction.

The approved single daily dosing will start to work in 15 minutes with peak effect at 3 hours and then waning effectiveness to 6 hours, and is most effective for those with mild presbyopia. It has only been studied for daily use for 30 days. Side effects can include eye irritation, headache, reduction in night vision.  Retinal detachment is its greatest risk.  The study population were mostly adults between 40-55.  It has not been studied in patients > 65 and should be used with caution in this population.

The company claims a new buffering formulation will be better tolerated than other formulations of pilocarpine. For patients who wear contact lenses, the lenses should be removed before administration and not reinserted until at least 10 minutes after administration.

The GoodRx price is about $85 for a 2.5 cc bottle that will last approximately 1.5 months when used daily. Like reading glasses, this will likely not be covered by insurance.

Mark’s Comments:

I actually first heard about this initially through television advertising. As a reading glasses wearer myself, I’m left wondering the appeal of such drops, though I certainly would have welcomed life without reading glasses during the “goggles/face shield” portion of the pandemic. The GoodRx price for 15 cc of 1% pilocarpine drops is as low as $26, so if I were tempted to try this, it’s hard to believe there would be a significant difference between the two strengths other than the price and the fact that the 1% was already available in generic form. My one caution (beyond the side effects) for those who may be prescribing this is to be sure those patients are receiving regular eye care.

Reference:

Product information for Vuity. Allergan, an AbbVie Company. North Chicago, IL. October 2021. Link

From PeerRxMed (www.PeerRxMed.org)

3)    Making Room for Recovery

“Energy, Not Time, Is Our Most Precious Resource” ― Jim Loehr, PhD How’s your energy? For some, the fact that I’m even asking that question might

provoke a visceral “you’ve got to be kidding me!” Over the past few weeks I’ve been hearing from colleagues across a wide swath of specialties who are “hitting the wall” – who feel like they’re running on empty physically, emotionally, cognitively, even spiritually. And while I wouldn’t claim “wall status” for myself (yet), I’m definitely having more “on the verge” moments as omicron continues to overwhelm our region.

If that at all describes you, I want you to meet Jim Loehr, whose work I was first introduced to almost 2 decades ago through a book he co-authored with Tony Schwartz called The Power of Full Engagement. By regularly practicing the precepts I learned back then, I have managed to stay on this side of the “verge” on many occasions over the course of the pandemic.

The premise of book revolves around 3 basic principles:

·         It is essential to manage our energy, not our time, as energy is our most precious individual resource.

·         We must attend to all four sources of internal energy in our life: physical, mental, emotional, and spiritual.

·         It is important to both acknowledge and accept that we each have limitations, though we likely underestimate what we are capable of when we learn how to better manage our energy.

A vital part of managing one’s energy is an understanding of the importance of recovery, which is about practicing regular rituals for the renewal of your energy and also continually re-focusing on your priorities in order to optimally focus that energy. As Loehr says, “Knowing how and when to recover may prove to be the most important skill in your life.” In other words, recovery does not happen by accident.

Intentional recharging and recovery happen on many levels, starting with frequent brief breaks during times of transition throughout the day as well as healthy eating, restorative sleep, regular physical activity, alignment to meaning, and connection with others. There is then the need for longer periods for rest, recharge and reconnection. These longer periods come in the form of weekly days off as well as periodic longer times for reflection and rejuvenation. In the military and some other organizations, this is called R&R (rest and recuperation) and is particularly vital for those who work under hazardous, stressful and/or difficult conditions. Sound familiar?

So how are you doing with your energy management? Are you carving out regular time for recovery? When’s your next vacation or even mini-vacation? For those of you who are “overdue, I want to invite you to the upcoming 5th annual Physician Health and Well- being Conference sponsored by the American Academy of Family Physicians and open to all physicians, nurse practitioners, and physician assistants. In full disclosure, I am serving as the conference chair for this conference and would love the opportunity to connect “live” with you. Here’s a link to learn more: Link

In our 23rd month of the pandemic, maybe it’s too much to be thinking about “thriving” right now, but taking steps to stay grounded and plugged in is more important than ever. I am committed to making this happen for me – and I’d invite you to do the same and allow others to help support you in those efforts. And it all starts with a decision to be sure you’re attending to managing your energy through creating times for regular recovery, and, of course, consistently connecting with life-giving family and friends.

Let’s get through this … together.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org