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15 Articles in Volume 20, Issue #6
20/20 with Mark Wallace: Where Cannabis Fits into Pain Practice
A Commentary on Opioid Stewardship: Fentanyl, Sufentanil, and Perioperative Pain
Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions
Advanced Practice Matters with Theresa & Jeremy: COVID, Pain, and Power
Analgesics of the Future: Inside the Potential of Janus Kinase Inhibitors
Application Note: Using Photobiomodulation to Treat Trigeminal Neuralgia
Case Report: Quadratus Lumborum Block for Managing Pathologic Pain to the Hip
Chronic Pain and the Short-term Effects of Medical Cannabis
Differential Diagnosis: Polymyalgia Rheumatica or Rheumatoid Arthritis
Genicular Nerve Blocks: Field Tips on Prognostic Value and Technical Considerations
Guideline Update: ACR Promotes Pharmacologic Treatment for Osteoarthritis
Navigating New York's Medical Marijuana Program: A Patient Handout
Person-Centered Care: Lessons from the VA’s Whole Health Model
Psychedelics for Chronic Pain: Is It Time?
Resident’s Corner: What Pain Medicine Education is Missing in the COVID Era

Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions

One-third of originally successful patients may relapse and return to pre-treatment levels or worse. How to keep them on track with medication and treatment regimens.

Approximately 125,000 people with treatable diseases die each year in the US because they do not take their medication as prescribed, while 10% to 25% of hospital and nursing home admissions result from uninitiated or incomplete prescribed treatment plans.1,2 On the research side, clinical trials report average nonadherence rates of 43% to 78% among patients receiving medication for chronic conditions.3  Behavioral change interventions related to obesity, substance abuse, smoking cessation, and chronic pain have shown similar relapse rates following completion of treatment.4

These statistics underscore the need for a continued understanding of the factors that impact treatment compliance, or adherence, and relapse in individuals with chronic pain. This article offers insight into the current understandings of compliance versus adherence and provides potential protective factors to maintain long-term gains in patients.

Clinical trial data shows average nonadherence rates of 43% to 78% among patients receiving medication for chronic conditions. (Image: iStock)

Defining the Terms: Compliance Versus Adherence

Aronson offers an in-depth review of the terms “compliance” and “adherence” in regard to prescribed treatment regimens.5 The review summarizes “compliance” as acting in accordance with the advice of a treatment provider. However, historical use of the term compliance has been criticized for its perceived unilateral demands on the patient to comply orobey. Other experts recommend the term “adherence” as an alternative.6,7 Adherence is described as the degree to which one consistently follows the treatment plan over time. Therefore, “nonadherence” would describe a patient who discontinued a prescribed treatment program or medication prematurely. The terms noncompliance and nonadherence, unfortunately, continue to be used interchangeably in the literature. However, in this article, we will proceed only using the term adherence.

Past research has identified variables related to nonadherence, including demographic variables, incentives, attitudes, and psychological variables (eg, denial, depression, dementia, cultural issues, and substance abuse). Additionally, social support (not just having people around) has been found to be an important variable related to treatment adherence.8 To date, researchers have not identified a key, single variable related to treatment adherence.9-11 Instead, a multivariate approach is recommended with the following factors in mind:12

  • The patient–provider relationship – including approachability, shared medical decision-making, and the amount of provider supervision, trust, and mutual respect
  • Inherent features of the treatment regimen – including complexity (eg, treatment costs), intrusiveness (eg, unpleasant side effects), duration, and patient knowledge of their condition
  • The therapeutic environment – including organizational structure, scheduling of appointments, continuity of care, and length of referral and wait times
  • Characteristics of the disease or injury – such as recognizability of the illness and unpleasantness of the symptoms
  • Client beliefs – such as believed credibility of the treatment,13 pain beliefs,14 and attitudes toward pain15
  • Characteristics of the patient – including prior experiences, identification of triggers,11 feelings of uncertainty, inconvenience, pessimism, motivation, and self-efficacy
  • Social support – including qualities of the patient social support system8 and degree of family conflict/cohesion16

 

How to Assess Adherence

There have been many measures developed and criteria employed to assess patient adherence to a treatment plan. One proposed criterion is that a minimum standard be used to achieve the desired health benefit.17 Adherence is generally measured as a continuum and should not be considered all-or-nothing. Investigators have recommended multiple indicators, including:

  • Self-report: these measures may be the easiest to obtain, the most frequently used, and easy to implement (eg, interviews and self-monitoring)
  • Behavioral: these tools include medication adherence (eg, pill counts or refills), activity levels (eg, pedometers and actometers), and attendance of sessions
  • Biochemical indices: these may be less subject to bias but also more expensive, less available and more and vulnerable to metabolic conditions
  • Clinical outcomes: these measures have been suggested as the “best” but there is no linear association; they also involve independent observers (eg, family and friends)

Frontline providers can formulate specific procedures for improving their own patients’ participation, such as by proactively assessing the risk of nonadherence, improving the patient-provider relationship, and educating the patient on their condition. It is important to customize treatment, enlist social support, and make use of other healthcare providers via referral or multidisciplinary care.12 For medication adherence, it is important to ensure the patient understands the medication and its side effects thoroughly.18

When Relapse Occurs

The term “relapse” is related to a loss of treatment gains or regression to pre-treatment baselines. One criterion for program success is that 30% to 70% of patients maintain gains, usually over one to five years. This goal also means that 70% to 30% of patients will not meet criteria for long term improvement (more on this below).19

Similarly, research has shown that approximately one-third of originally successful patients will relapse and return to pre-treatment levels or worse.20,21 As a result, practitioners and researchers alike are interested in better understanding the variables related to treatment success. Some teams have identified the importance of long-term maintenance or skills,22 while other investigators have experimented with length of treatment, booster sessions, and assessing and addressing high-risk situations that foster decline – but these strategies do not appear to resolve the issue of relapse.23 Instead, research has shown time and again that the chance for a relapse can be reduced if the skills learned are generalizable, translatable to the patient’s life, and continuously reinforced.24,25

As a field, it is therefore valuable to develop and use treatments that enhance generalization of gains to interdependent aspects of wellness rather than just evaluating the effectiveness of a specific pain-related outcome from specific modalities.26

How to Keep Patients Moving Forward

There are evidence-based strategies providers can use to help maintain long-term gains in their pain management care, including building the therapeutic relationship, motivational interviewing, and health coaching interventions.Traditionally, a hierarchical, authoritarian approach was used in medicine. It has since been evolving toward a more collaborative partnership between the patient and provider, based on mutual goals and a shared understanding of the importance of the medical problem. Also factoring in are discussions around the availability of effective treatments and the risks if the condition remains untreated or undertreated.

The Therapeutic Alliance

The therapeutic alliance, or therapeutic relationship, is a psychotherapeutic common factor identified by Grencavage and Norcross27 that has been utilized in a recent meta-analysis as impacting behavioral treatment adherence, specifically in chronic headache patients.11 Therapeutic relationship factors are characteristics of the provider and the patient that facilitate change and are considered a common factor across treatment types. One must keep in mind, however, that government health programs and private payers have adopted various reforms that fundamentally transform this relationship.28 For example, public reporting and payment reforms incentivize providers to improve the quality and efficiency of care they provide to patients but may also induce providers to reject high-risk, treatment-resistant patients.28

Despite these barriers, frontline providers can build their patient relationships by employing empathy, warmth, respect, genuineness, acceptance, encouragement, instruction, and communication. For example, communication skills that reflect a nonjudgmental attitude, with an openness to explore the patient’s beliefs and concerns, enable clinicians to collaboratively negotiate a treatment plans that will improve patient outcomes. Research has shown that providers participating in brief communication skills training improves outcomes in primary care settings for patients with fibromyalgia and acute pain.29

Motivational Interviewing

Frontline practitioners may also want to be trained in and employ motivational interviewing (MI), which is another technique to help maintain long-term gains. MI was developed in the early 1980s in the treatment of alcohol and substance abuse. MI is a patient-centered, directive technique, aimed at improving the motivation and commitment of patients who may be ambivalent to achieve behavioral changes.30 The spirit of MI includes collaboration, respect for autonomy, and elicitation.31 There are four main principles to use when applying MI: expressing accurate empathy, developing discrepancy, avoiding argumentation and rolling with resistance, and supporting self-efficacy.32

MI principles are now being applied to the management of chronic conditions, such as chronic pain. Motivational interviewing offers different strategies depending on how ready and motivated the patient is for change. The technique has been shown to have a positive effect on adherence to behavioral programs for coping with pain.33-35 Other constructs include self-efficacy and locus of control, which have also been found to significantly impact treatment process and outcome.11,36 (More on motivational interviewing techniques.)

Health Coaching

Health coaching interventions have also been reported to improve health outcomes for individuals with chronic diseases, including chronic pain.37 These interventions – commonly referred to as life coaching or wellness coaching – lack definitional clarity, which has made it difficult to study or compare coaching interventions.38 Health coaching is a patient-centered approach where patients use self-discovery combined with educational content to work toward their desired goals and self-monitor their behaviors to increase accountability with their coach.39 Most forms of coaching build solutions, focus on goal attainment, and are based on the core assumption that people have an innate capacity to grow.40

Conclusion

Pain practitioners often face challenges related to noncompliance and nonadherence to treatment plans and medication regimens. Relapse may be expected in some patients. However, long-term gains can be made by strengthening the patient-provider relationship and using patient-centered education tools such as motivational interviewing and health coaching.

 

Disclaimer: The views expressed in this article are those of the author and do not represent the views of the Department of Veterans Affairs or any other governmental agency.

 

Continue Reading:
Pain Assessment Tools for Malingering in Patients with Chronic Pain
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