Perceptions of nonopioid treatment for pain in a homeless population

Participants

The 200 voluntary participants interviewed for this study were guests of TWP in Fort Worth, Texas and were not screened for opioid addiction or use of pain medication before beginning the questionnaire. TWP was chosen because the shelter is a site for the University of North Texas Health Science Center’s (UNTHSC) Homeless Outreach through Medical Education (HOME) Clinic. TWP provided written consent allowing research to take place at their location. This study was approved by North Texas Regional Institutional Review Board (IRB# 1340830-1).

Materials

A consent form was provided to participants that outlined the purpose of the study, risks and benefits, an agreement to participate, a confidentiality statement, instructions on how to leave the study, and contact information for the principal investigator for questions after completion of the study. Other materials included a page defining terms used in the survey, stamp cards provided by TWP, stamps borrowed from TWP, and the survey (Supplementary Material). (One stamp on the TWP stamp card was given upon completion of the questionnaire; the stamp cards could be redeemed at TWP for laundry, lunch, toiletries, clothing, et cetera.) The stamp cards were provided by TWP and the stamps were borrowed and returned to TWP upon completion of the study at no cost to the investigators. The survey was designed by the researchers (K.F., J.B., A.P.) and is not validated nor based on a validated survey. It included three demographic questions about the participants’ age, sex, and ethnicity in an open ended format, as well as 22 binary (yes/no) questions and seven multiple choice questions, one of which had a free response option. These questions assessed the perception and current use of each of the opioid and nonopioid treatment modalities (physical and massage therapy, chiropractic treatments, and OMT) among the study population. The questionnaire did not collect any protected health information (PHI) that could be used to identify the study subjects.

Design and procedure

Surveys (Supplementary Material) were conducted during three 4 hour sessions from February 2019 to April 2019 during the hours of the UNTHSC HOME Clinic. Participants were included in the study if they were over 18 years of age and English-speaking. Exclusion criteria included pregnancy (determined by asking if the participant was pregnant), cognitive impairment (determined by if the participant could verbally demonstrate they understood information presented in the consent process), and employment at TWP. Participants were approached in the common areas of TWP by researchers clearly identifiable as UNTHSC students (K.F., J.B., H.N., F.P., A.W.) and were asked if they were interested in participating in a questionnaire. Potential participants were explicitly told they had the right to refuse to participate at any time during the survey. If they agreed to participate, the researcher verbally reviewed the consent form with the participant. If the participant needed clarification about different terms, they were provided with standardized definitions and examples. OMT was described as, “OMT is a hands-on approach performed by physicians to treat pain caused by bones, muscles, and nerves.” Physical therapy was described as, “Physical therapy is a way to treat injuries that include exercise, stretching, and massage.” Massage therapy was defined as, “A massage therapist uses his or her hands to rub muscles and joints of the body to relieve pain.” Chiropractic treatments were described as, “Chiropractors use hands-on manipulation to align the body’s bones, particularly the spine.” Examples of opioid medications included, “Tylenol 3, Tylenol 4, Ultram, Oxycontin, methadone, and morphine.” If the participant gave verbal consent after reviewing the consent form, the researcher read the questionnaire, one question at a time, and recorded the participant’s responses through multiple choice, binary, and free text components on a paper questionnaire. After the questionnaire was completed, the participants received the consent form for their records and one stamp on their TWP stamp card.

Data analysis

At the end of each session, survey responses were recorded by the student researchers (K.F., J.B.) on a spreadsheet. The survey responses were exported to the NCSS software package (NCSS 11 Statistical Software 2016; NCSS LLC) for analysis. Appropriate descriptive statistics for nonparametric data were selected to test for significant differences between the five treatment modalities (opiates, OMT, physical therapy, chiropractic, and massage therapy) addressed in the survey. For binary response questions, Cochran’s Q test was first employed to test for significance (p<0.05) amongst the groups, followed by multiple comparisons using absolute difference to test for pairwise proportional differences among treatment groups. The correlation between two nonparametric variables was tested by calculating the odds ratio (OR) and confidence interval (CI); significance was verified by McNemar test (p<0.05).

Chronic pain and mental health

Although the causational relationship is unclear, it is known that addiction, depression, and other mental disorders are associated with chronic pain [2], [13]. In some individuals, these mental health issues are due secondarily to their pain, but in others, mental health issues predate the onset of pain. Oftentimes, the presence of these psychiatric issues exacerbates the degree of pain felt by patients and also impedes the rate and significance of recovery [13]. OMT has shown to decrease mental health issues in various studies and more recent studies have addressed the biopsychosocial aspect of OMT treatment [14], [15], [16]. The ROMANS trial found that OMT had significant improvement on short and long term psychological outcomes, even after the physical effects of OMT were no longer significantly different from the control group [16]. In a more recent study, the results revealed that OMT was effective in reducing chronic pain, anxiety, and other psychiatric disorders [14]. A major component of OMT focuses on the musculoskeletal aspect of the human body and can address the physicality of chronic pain. However, these studies show that mental health is implicated in chronic pain, and OMT could potentially address chronic pain, not only at a physical level, but also in cognitive and emotional facets of health. This is especially important as chronic pain and mental health issues are highly prevalent in the homeless population [2], [3].

Limitations

One of the limitations of our study is that we did not collect any PHI, so we were unable to prevent repeated sampling. TWP is a short term facility with approximately 8,500 guests per year, so the spacing of questionnaire dates helped decrease the risk of repeat surveys and convenience sampling. To avoid repeat sampling in future studies, PHI could be collected or a question could be added to query about previous participation.

Our survey not being validated could have potentially added bias into the study, and the interpretation of the data is therefore limited. There were multiple surveyors; however, the survey conducted consisted of categorical answers and the free responses in the comment section were not included in the analysis. Moreover, two researchers (K.F., J.B.) were responsible for recording all survey responses.

Because the researchers identified themselves as students from an osteopathic medical school, there may have been reporting bias in the answers, as participants could have provided answers that favored OMT and the osteopathic curriculum. Another limitation is potential sampling bias, as some participants may have been more motivated to participate to acquire stamps to redeem for TWP amenities and services.

One aspect that we did not address was the efficacy of opioid medication on decreasing pain in this population. This was a survey study with the purpose of assessing the willingness of the homeless population to pursue OMT as an adjunct treatment for pain. Although we are unsure whether participants were using opioids during the timeframe that they received OMT treatment (for those who did), our population demonstrated current use of alternate pain management methods and a willingness to try manipulation, including OMT, with increased availability. As such, further research is needed to investigate whether increased OMT awareness and knowledge in this population would affect their utilization of OMT. Efficacy could also be studied by assessing pre- and posttreatment pain levels among guests at homeless shelters, as well as how OMT treatment would affect other biopsychosocial aspects of pain such as addiction, depression, anxiety, and posttraumatic stress disorder.