From the Guidelines
Cognitive behavioral therapy (CBT) is recommended as an additional therapy for chronic pain management, as it promotes patient acceptance of responsibility for change and the development of adaptive behaviors. This recommendation is based on the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV, which states that CBT is recommended for chronic pain management with a strong, moderate level of evidence 1.
When considering additional therapy, a healthcare provider would:
- Evaluate the effectiveness of current treatments
- Assess any ongoing symptoms or side effects
- Consider the patient's overall health status and any comorbidities
- Review potential drug interactions with existing medications
- Determine if there are any contraindications to new therapies Possible additional therapies could include:
- Adjusting dosages of current medications
- Adding a complementary medication to enhance treatment effects
- Incorporating non-pharmacological interventions (e.g., physical therapy, yoga)
- Exploring alternative treatment modalities if conventional approaches have been exhausted
Other options, such as acupuncture, massage therapy, and thermal modalities, may also be considered, but the evidence for these interventions is generally of lower certainty, as noted in the 2022 American College of Rheumatology guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis 1.
In general, the choice of additional therapy should be based on a thorough clinical assessment and discussion with the patient about their goals and preferences, and any new treatment should be carefully monitored for efficacy and potential adverse effects. The most recent and highest quality study, such as the 2022 American College of Rheumatology guideline, should be prioritized when making a definitive recommendation 1.
From the FDA Drug Label
Patients should be periodically reassessed to determine the need for maintenance treatment.
Dosage adjustments, which may include changes between dosage regimens (e. g., daily throughout the menstrual cycle versus during the luteal phase of the menstrual cycle), may be needed to maintain the patient on the lowest effective dosage and patients should be periodically reassessed to determine the need for continued treatment
The recommended additional therapy is maintenance treatment with sertraline, with periodic reassessments to determine the need for continued treatment and dosage adjustments as needed to maintain the patient on the lowest effective dose 2, 2.
- Maintenance treatment is recommended for several months or longer beyond response to initial treatment for conditions such as major depressive disorder, posttraumatic stress disorder, social anxiety disorder, obsessive-compulsive disorder, and panic disorder.
- Dosage adjustments may be necessary to maintain the patient on the lowest effective dose.
- Periodic reassessments should be performed to determine the need for continued treatment.
From the Research
Additional Therapy Recommendations
Based on the provided evidence, the following additional therapies are recommended:
- Single component interventions, such as education or motivational interviewing provided by a health professional, can help to improve adherence to pharmacotherapy 3
- Multi-component interventions, including tailored care packages that include adherence support as a key component or inhaler technique as a component, may result in more people adhering to pharmacotherapy compared to control 3
- Mindfulness and cognitive-behavioral therapy-based interventions are effective in reducing stress, anxiety, and depression in physicians and nurses 4
- Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications 5
- Technology-based interventions can improve the efficacy of treatment for anxiety and obsessive-compulsive spectrum disorders, but there are challenges to achieving this goal 6
- Multicomponent, psychological, and exercise interventions can improve pain self-efficacy in people with chronic musculoskeletal pain, with small effects at follow-ups of 0 to 3 months, 4 to 6 months, and 7 to 12 months 7
Key Findings
- The evidence suggests that single component interventions, such as education or motivational interviewing, can improve adherence to pharmacotherapy 3
- Multi-component interventions, including tailored care packages, may result in more people adhering to pharmacotherapy compared to control 3
- Mindfulness and cognitive-behavioral therapy-based interventions are effective in reducing stress, anxiety, and depression in physicians and nurses 4
- Behavioural only or mixed educational and behavioural interventions may improve medication adherence in older adults prescribed multiple medications 5
- Technology-based interventions can improve the efficacy of treatment for anxiety and obsessive-compulsive spectrum disorders, but there are challenges to achieving this goal 6
- Multicomponent, psychological, and exercise interventions can improve pain self-efficacy in people with chronic musculoskeletal pain 7
Intervention Types
- Single component interventions:
- Education
- Motivational interviewing
- Adherence aids (e.g. Bluetooth inhaler reminder device)
- Multi-component interventions:
- Tailored care packages
- Inhaler technique
- Mixed educational and behavioural interventions
- Technology-based interventions:
- Mindfulness and cognitive-behavioral therapy-based interventions
- Online platforms
- Mobile applications
- Exercise interventions:
- Multicomponent exercise programs
- Psychological therapies (e.g. cognitive-behavioral therapy)