Post on 27-Jun-2020
The new Chronic Pain program
at CHEO Mental Health Series, June 14th, 2017
Christine Lamontagne, MDCM, FRCPC
Medical Director of Chronic Pain Services
Children’s hospital of Eastern Ontario
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Declaration of Conflict
Speaker has nothing to disclose with regard to commercial support.
Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.
Partner Presentation
CHEO and the Royal work closely and actively with many community agencies and health care providers.
This presentation is brought to you by one of our local partners. The information and views presented today represents that of our partner organization.
Objectives
1) Define pediatric chronic pain. 2) Define the prevalence of pediatric chronic pain in The
Greater Ottawa Area 3) Define the impact of chronic pain in children 4) Explain the role of the Ontario Pediatric Chronic Pain
Network 5) Why the 3 P approach to pediatric chronic pain
management? 6) Describe CHEO’s new interdisciplinary chronic pain
program 1) Referral criteria 2) Priority ranking and wait times 3) Types of conditions seen 4) Proposed interdisciplinary model of care 5) Discharge criteria and Transition to adult care
Acute vs Chronic Pain
Acute Pain
(Less than 3
months)
Chronic Pain
(More than 3 months)
Cause Usually single
obvious cause
(tissue damage)
May be associated with disease, but cause is
often unclear; can be a disease in its own
right
Mechanism Usually nociceptive
(triggers sympathetic
response)
Often neuropathic
( may cause autonomic dysfunction)
Purpose PROTECTIVE NOT PROTECTIVE
Pain
Intensity
Proportionate to
tissue injury
Often out of proportion to physical findings
Treatment Treatment of
underlying cause
usually alleviates the
pain
More difficult to treat, requiring
multidisciplinary, multi-modal treatment
approach (3’P’s)
Prevalence of chronic pain in children and
adolescents. The epidemiology of chronic pain in children and adolescents
revisited: A systematic review. King , Chambers, Huguet, MacNevin, McGrath, Parker,
MacDonald. PAIN 152 (2011) 2729–2738
• Chronic and recurrent pain is prevalent in children
and adolescents, with girls generally experiencing
more pain than boys and prevalence rates increasing
with age.
• Psychosocial variables impacting pain prevalence:
anxiety, depression, low self-esteem, other chronic
health problems, and low SES.
Pain type Prevalence
range
Age
difference
Sex
difference
Factors associated
with increased
prevalence
Headache 8–82.9% Older > younger Girls > boys Presence of anxiety and
depression; low self-
esteem; positive family
history of headache; low
SES
Abdominal
pain 3.8–53.4% Younger > older Girls > boys SES ; emotional
symptoms; school stress
Back pain 13.5–24% Older > younger Girls > boys Emotional symptoms
MSK/ limb pain 3.9–40% Older > younger Girls > boys Feeling sad
Multiple pains 3.6–48.8% Unclear Girls > boys Chronic health problems;
frequent change of
residence; frequent
television watching; poor
school performance;
fewer interactions with
peers
generalized
pain 5–88% Unclear Girls > boys Poor self-rated health;
feeling low or irritable;
bad temper; feeling
nervous
Prevalence of debilitating pediatric chronic
pain in Greater Ottawa Area • 2-8% of children have pain symptoms that can be
severe enough to interrupt sleep, restrict physical activity and prevent them from attending school. ( Finley, Chorney & Campbell, 2014)
• From Statistics Canada: children population (0-19 yo) in Ottawa/Gatineau area from 2016 census : 306 740
• Estimate of number of children with severe delibitating chronic pain in Greater Ottawa Area:
2% of 306 740 = 6134 patients
8% of 306 740 = 24 539 patients Reference: http://ottawa.ca/en/long-range-financial-plans/economy-and-
demographics/population, www.Canadian painsociety.ca
When Pain Persists
• Fallout of Chronic
Pain …
– Anxiety
– Depression
– Poor sleep
– Poor Quality of Life
– Suicide
– Chronic pain in
adulthood
Family dynamic
Friends
School
absenteeism
Extracurricular
activities
Family’s Finances
Rest, passive
coping
Chronic Pain Risk Factors: neuropathic pain component, central sensitization
predisposition, intensity of acute pain,
psychosocial vulnerability 1
Perceived
tissue damage
Limited activities
Weak tight muscles
Withdrawal from social
and physical activities
Anxiety, depression,
anger
Pain-
centered
life
Tissue
damage
THE CHRONIC PAIN SPIRAL: EVOLUTION FROM ACUTE TO CHRONIC PAIN
ABéland MD 2012 | Abeland@Live.ca P Lavand’homme. The progression from acute to chronic pain. Current Opinion in Anesthesiology 2011;24:545–550. Adapted from: http://prc.canadianpaincoalition.ca/fr/chronic_pain_and_disability.html
Physical and
psychosocial
deconditioning
This working group will focus on: Flow of Patients Through System Core Staffing Requirements Requirements of Registry & Portal Process Standards
This working group will focus on: Training development Development and delivery of training and education programs, including outreach to primary care providers.
This working group will focus on: Development of Measures for Program Evaluation & Performance Risk Identification & Mitigation Research Program identification & development Research dissemination Registry Development
This working group will focus on: Clinical Standards Treatment Algorithms Clinical Operations
14
Organizational Structure
Paediatric Chronic Pain Network
Ontario Chronic Pain Network
Pediatric Chronic Pain Network
Advisory Board
Education and Training
Research and Evaluation
Patient Care
Strategy
Adult Chronic Pain Network
Advisory Board Co-chairs – Salisbury, LaMontagne, Campbell
Ontario Pediatric Chronic Pain Network
(PCPN)
• CHEO’s involvement: Co-chair and Leadership representation at Advisory Board and multiple chronic pain team members involved in subcommittees, patient care, research and education and training
• Sites funded for outpatient interdisciplinary pain programs/ clinics: Toronto , London, Hamilton and Ottawa
• Sites funded for intensive pain rehabilitation program: – Holland Bloorview Rehabilitation (Toronto) now accepting
patients for inpatient (2 weeks)/outpatient( 2-3 weeks( rehab treatment based on 3 P, referrals coming from individual pain clinics only
Managing Pain & Dysfunction: the 3 P
approach
Physical/Rehabilitative
Medical
-Pharmacological - Interventional (nerve
blocks, IV lidocaine infusions)
Psychosocial
Self
Management
Active coping
Self Management
Skills
Increased
activity
Improved
Social
Functioning
↓Anxiety, depression,
anger
Function
centered
Life
CHANGING THE CHRONIC PAIN SPIRAL: FUNCTION- CENTERED LIFE
ABéland MD 2012 | Abeland@Live.ca Adapted from: http://prc.canadianpaincoalition.ca/en/self_management.html
Physical
reconditioning
Pain- centered
life Analgesia
Education
Treatment of
neuropathic/chronic pain
First Line
•TCA (amitriptyline,nortriptyline)
•Gabapentin or Pregabalin •SNRI (duloxetine, venlafaxine)
Second Line
• Tramadol
Other Opioids *
Third Line
• Cannabinoids*
Fourth Line
•Carbamazepine, valproic acid, topiramate, lamotrigine
•Topical Lidocaine (5% gel or cream); Lidocaine patch N/A •SSRI •Methadone
Add additional agents sequentially
if partial but inadequate pain relief;
Attention to synergistic/additive side effects
Pharmacological management of chronic neuropathic pain: Revised consensus
statement from Canadian pain Society. Pain Res Manag. December 2014
Acetaminophen
NSAIDs
Anticonvulsant drugs
Opioids
Local anesthetics
ASCENDING PATHWAYS
DESCENDING PATHWAYS
Enhancement of pain modulation by descending pathways1,3-5
Tricyclic antidepressants
Serotonin/ norepinephrine reuptake inhibitors
Anticonvulsant drugs
Opioids
Inhibition of pain signal transmission in ascending pathways1,2,4,6
MECHANISMS OF ACTION OF SELECTED ANALGESICS
1. Vanderah TW. Med Clin North Am. 2007;91(1):1-12. 2. Becker DE, Reed KL. Anesth Progr. 2006;53:98-109. 3. Tanabe M et al. Brit J Pharmacol. 2005;144(5):703-714. 4. Knotkova H,
Pappagallo M. Med Clin North Am. 2007;91(1):113-124 . 5. Benarroch EE. Neurology. 2008;71:217-221.6. Carver A. In: ACP Medicine. New York, NY: WebMD; 2005:section 11,
chap 14.
Mental health disorders in pediatric
chronic pain population Vinall, Jillian et al “Mental Health comorbidities in pediatric chronic pain: A Narrative
review of Epidemiology, models, neurobiological mechanisms and treatment”. Children
3.4 (2016):40
• High co-occurrence of PTSD, anxiety, depression,
somatization and conversion disorder, ODD(boys), ADHD(boys)
in 30-50% of pediatric chronic pain patients
• Shared neurobiology (cortisol, serotonin, BDNF, inflammatory
markers)
• Common predisposing affective, cognitive and behavioral
factors
• High risk of developing mental health disorders in adulthood
even when pain has resolved. Anxiety (OR 1.33), depression
(OR 1.38)
• Temporality? Anxiety seems to precede pain
Environmental factors
• Co occurrence of Parental mental health diagnosis
and pediatric chronic pain (anxiety, depression,
somatization)
• Peer victimization
• Social isolation
What are the chronic pain services currently
offered at CHEO?
• New Assessments: on average 9-11 new patients per month.
• Follow ups: outcome measures gathered at 3, 6 ,9, 12, etc
months. Patients are usually followed for 1-2 years
• Patient-Reported Outcomes Measurement Information System
(PROMIS) for the provincial registry which includes both
pediatric self-report and parent proxy measures on • demographic information
• pain description
• school and learning details
• family dynamics
• health care utilization
• past physical, psychological/ psychosocial and pharmacological treatments
• a sleep questionnaire
• a pain catastrophizing scale, anxiety and depression screening
Realistic Goals with medications or
interventions
• 30-50% pain reduction is realistic
• Total pain relief is an unrealistic goal
• Ideal: improve function with minimal side effects,
reduce pain
- Function -Pain Relief
- Adverse Effects
NNT in order to get 50% pain reduction
NNT = Numbers needed to treat; from Finnerup et al. (2005) Pain 118: 289-305
Opioids in pediatric chronic pain
• Used or indicated only in selected patients ( tramadol,
morphine, hydromorphone)
• Has to be used as a tool in the setting of a 3 P approach to pain
management.
• If not helpful in maintaining or increasing function, then should
be discontinued
• Most patients report feeling more depressed when taking
opioids with minimal benefit for their pain (concepts of tolerance
and hyperalgesia)
• Teenagers are at Higher risk for opioid addiction, diversion or
misuse. Opioid contract and frank discussion is a must.
• Contraindicated in chronic headaches
What are the outpatient pain services
currently offered at CHEO?
• APS/ transition pain clinic: for persistent postop
pain and pain less than 3 months. Patients seen by
NP and physician only. Goals: manage pain
medications and initiate referrals for physio or
psychology, help prevent chronic pain and disability.
• Chronic pain clinic: interdisciplinary assessment
and follow ups of patients with pain lasting greater
than 3 months
• What about for inpatients? Acute Pain
Service(APS), PSMT (palliative) and Chronic pain
Service (CPS)
What are the chronic pain services currently
offered at CHEO?
• New Assessments: on average 9 new patients per month.
• Follow ups: outcome measures gathered at 3, 6 ,9, 12, etc
months. Patients are usually followed for 1-2 years
• Patient-Reported Outcomes Measurement Information System
(PROMIS) for the provincial registry which includes both
pediatric self-report and parent proxy measures on • demographic information
• pain description
• school and learning details
• family dynamics
• health care utilization
• past physical, psychological/ psychosocial and pharmacological treatments
• a sleep questionnaire
• a pain catastrophizing scale
Main goals of the chronic pain program
• Improve Function first then decrease pain. It is NOT
about elimination of pain or finding an organic cause
for the pain
• Develop a virtual pain tool box where child/youth
incorporates and learns strategies to manage pain:
pharmacological, physical and psychological
• Provide support and education for parents to help
manage their child’s pain with this 3 P approach.
• Very important that patients have been appropriately worked up
by referring physicians or PCP so that they are ready to engage
in rehabilitation model of care and not searching for a cause.
Patient Groups/Conditions seen at CHEO
• Post concussion pain syndrome
• Chronic headaches, not responding to prophylactic therapy
• Neuropathic pain: CRPS type 1 and type 2, post
traumatic nerve injury, post surgical pain
• Recurrent Abdominal Pain: IBS, abdominal wall pain,
post surgical, IBD…
• MSK: fibromyalgia, post viral myofascial pain
syndromes, JIA
• Congenital disorders: EDS, mitochondrial disorder,
etc
The interdisciplinary team at CHEO
• Anesthesiologist/ pain physician(0.5 FTE)
• Nurse coordinator(FTE: 1.0)
• Physiotherapist (FTE: 2.2)
• Social worker (FTE:1.0)
• Occupational therapist (FTE:0.4)
• Psychologist (FTE:2.0)
• Pharmacist (FTE:0.4)
• Administrative staff (FTE:1.0)
• Nurse Practitioner( FTE:0.8)
• Psychiatrist (FTE:0.5) still looking for
What are the Referral criteria for Chronic
Pain Services?
• Pain as primary issue lasting greater than 3 months
• Ages 0-17.5 years old
• Six months or less from 18 years old :
– Assessment only and referral back to PCP or referring physician
for pain management
– Education sessions will be provided if possible
– Referral to adult pain clinic will be initiated by PCP.
• Chronic pain impacts function (school attendance, sleep, mood,
quality of life and/or family functioning)
What are the Referral criteria for Chronic
Pain Services?
• Other significant medical or mental health issues have either
already been addressed or are concurrently being addressed by
the appropriate professionals (e.g.active suicidality)
• Investigations to identify etiology of pain have been completed
• Pain refractory to attempted management strategies (ex:
commonly used analgesics, physical or psychological
therapies), or therapies not available in community despite best
efforts
• Primary provider/referring physician agrees to collaborate in
ongoing pain management follow-up including writing
medication prescriptions when indicated and transition planning
where possible
Referral process
• Referral accepted via epic or by fax
• Triaged according to information provided on referral
form and chart review
• Denial of referral if all criteria are not met.
Priority Ranking
• Urgent (2-3 months): painful severe condition with risk of duration or chronicity (e.g. new CRPS), neuropathic pain, Inability to function in ADLs
• Semi-urgent (3-6 months): severe or progressive pain and risk of increasing functional impairment. Patient is able to function but limited
• Elective (6-9 months): persistent long-term pain without significant progression. Patient is functioning but pain has impacted some areas of his/her life.
Our model of care
• Mild, moderate and severe disability
• Most patients( mild-moderate) go through an outpatient day care treatment : – less intensive than a day program
– Family education included
– 3P approach: pharmacological (medications, vitamins, nerve blocks, infusions) , physical (physiotherapy, OT, home exercises, community massage therapy, acupuncture) , psychology (CBT, psychoeducation on pain, mindfulness, SW intervention with parents and family as needed)
– Outreach/consultation to schools by social worker
– Periodic follow-up with interdisciplinary team at 3,6 ,12 months and as needed
Intensive outpatient program: Rise Above
pain (RAP)
• Pilot project of group intervention (7 patients)
• 8 weeks, 3 hours sessions for patients and parents
• Psychoeducation on pain, introduction to CBT,
mindfulness, sleep hygiene concepts, lifestyle
balance, info on pharmacotherapy, pool session,
stretching, concepts of pacing and gradual return to
functioning
• Results: 1 dropout, 2 discharges, increase
functioning and lower pain scores
• Excellent satisfaction scores from patients and
parents
Intensive outpatient program: Rise Above
Pain (RAP)
• Pilot project of group intervention (7 patients)
• 8 weeks, 2-3 hours sessions, youth & parent groups
• Content
– Psychosocial: Psychoeducation on pain, MI, CBT, sleep hygiene concepts,
occupational balance, principles of ACT, emotion education, relaxation &
mindfulness, pain and the family, pain behaviours & communication, stress & coping
– Physical: pool session, stretching, goal setting, concepts of pacing and gradual return
to functioning
– Pharmacology : info on pharmacotherapy, golden rules of taking prescribed
medication, individual medication consults
– Pain flare management using the 3 “P” approach & graduation
• Results
– 1 dropout, 2 discharges, increase functioning and lower pain scores
– Excellent satisfaction scores from patients and parents
Our model of care
• Patients who are more debilitated or fail to improve
with the outpatient treatment program will be referred
to an intensive rehabilitation program (3-4 weeks):
– Based on the 3 P approach: pharmacological, physical
and psychological
– Holland Bloorview Rehabilitation Center
– Referral to US chronic pain rehab. centers( Cleveland,
Boston, Philadelphia) only if not eligible for Holland
Bloorview
Systematic Review on Intensive
Interdisciplinary Pain Treatment of
Children With Chronic Pain Tanja Hechler,, Marie Kanstrup, Amy Lewandowski Holley, Laura E. Simons,
Rikard Wicksell, Gerrit Hirschfeld, Boris Zernikow,, Pediatrics,2015;136;115
• 1 RCT and 9 nonrandomized treatment studies identified
• Studies included if :(1) treatment coordinated by 3 health
professionals, (2) inpatient/day hospital setting(mean 16 days)
(3) age < 22 yo (4) debilitating chronic pain. Most had parental
education (minimize response to pain behaviors, encourage functional
behaviors)
• 5 outcome domains (pain intensity, disability, school functioning,
anxiety, depressive symptoms) at baseline,posttreatment, and
follow-up.
• Post treatment: large improvements for disability, pain intensity
and pain catastrophizing , small to moderate improvement for
depressive symptoms. Positive effects maintained at 3-12
months
• Large heterogeneity in outcome measures used
What are the benefits noticed since
implementing an interdisciplinary chronic
pain team at CHEO?
• From patient’s perspective: increase in functioning,
decrease in pain and depression. Most patients have
higher functional scores and lesser pain scores on
discharge. Less opioid use, less medication use
• From parental perspective: less anxiety, less
catastrophizing, less miscarried helping
• From a hospital perspective: less ER visits, less
hospital admissions, shortened admission time,
decrease in multiple health care providers being
involved
+ Chronic Pain outpatient Groups
Comfort Ability
Young Adult Group
PT/OT Education Session
Transition Group
Pain Flare Group
Chronic Pain Info Session
The Psychosocial P
• High co-occurrence of patients with Chronic Pain and mental health difficulties (e.g. mood, anxiety, acceptance of pain), as well as difficulties with social and family functioning
• Psychosocial P offers the following services:
– Psychoeducation about pain and emotions
– Brief, short term individual psychotherapy therapy & occupational therapy
– Group therapy (The Comfort Ability; Young Adults transition group; R.A.P. intensive day program)
– Parent support (individual & groups)
– Consultation with community providers & schools
The Comfort Ability
• Brief Intervention designed for 10-17 year olds with chronic pain
• Rooted in Principles of Cognitive Behavioural Therapy
– Motivational interviewing, psychoeducation about pain, biobehavioural strategies,
cognitive strategies, active/passive coping, anxiety & depression, communication
strategies, individual comfort plan
• Developed by:
– Dr. Rachael Coakley, PhD , Psychologist
Associate Director, Pain Treatment Service
Boston Children’s Hospital (BCH)
Assistant Professor, Harvard Medical School
• Separate, simultaneous youth and parent session
The Comfort Ability at CHEO
• Runs every 6-8 weeks on Sundays
• Target Audience
• Youth aged 10-17 years and their parents
• CHEO patients who have been seen in the Chronic Pain
Interdisciplinary clinic
• Various pain presentations, various levels of disability
• 1 day workshop (6 hours)
• Provide foundation of skills as early as possible in their
rehabilitative process
• Currently collecting data to evaluate effectiveness at CHEO
Preliminary Data from BCH (Coakley, 2015)
– Online self-report questionnaires for parent and child administered
pre-treatment, 1-week, 1-month, and 3-month follow up
– N=136
– Ages 10-17
– Various pain problems (headache, abdominal pain, neuropathic
pain, wide-spread body pain)
– At least one participating parent (but collected data from two if
possible)
– Families received $30 gift card for participation
Preliminary Data from BCH: PARENT group (Coakley, 2015)
• More adaptive parenting practices (e.g., fewer responses to child’s symptoms)
• Reduced catastrophizing of their child’s pain
• Increased confidence that their child can better manage his/her own pain
• Reduced healthcare utilization ( e.g., admissions, emergency visits, calls to
health care providers)
• Increasing gains through 3-months post-treatment
• Very high rates of patient satisfaction
Preliminary Data from BCH: YOUTH group (Coakley, 2015)
• Improved pain self-efficacy (e.g. feeling as though they can make it
through a day of school with pain)
• Reduced catastrophizing of symptoms
• Improved function (e.g. fewer naps during the day)
• Reduced pain
• Improving gains through 3-months post-treatment
The Physical P
• People with chronic pain tend to demonstrate: – Poor flexibility
– Decreased strength
– Poor endurance
• Many people who experience pain have a poor occupational balance: – Their function is decreased in the areas of self-care, leisure
and/or productivity.
– Participation in activities that are meaningful can be limited
What the team offers (Physical P):
• Entry point to individual PT and OT services = PT/OT Education Class – Group format for education and goal-setting using the Canadian Occupational
Performance Measure (COPM)
• Individual PT/OT sessions may then be initiated or recommendations may be made to start or continue therapy with community providers, depending on the goals identified through the COPM
• Treatment may include: Education, pacing, specific exercise programs, myofascial release, mirror therapy and/or recommendations for adjunctive therapies (eg. massage, acupuncture)
• Goals are around optimizing function (assist with return to sports, school, leisure activities)
Discharge criteria
• Youth and family fail to engage in proposed treatment
despite efforts by the team to address patient/family’s
concerns
• Patient, family and pain team feel that pain is well
managed and under control and support a transition
back to primary care provider.
• Age (18 yo)
Transition to adult care
• Youth transition group workshops: lead by our clinical
psychologists with aim to teach patients how to
advocate for self and develop comfort ability plan
going into the adult health care scene.
• Transition back to PCP for medication management
• Availability of econsult : Tool to help manage patients
on wait list and help PCP to manage patients once
discharged from our program
• Soon to restart: combined clinics with TOH pain clinic
for patients still needing more support
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www.cheo.on.ca/en/chronic-pain-service-pain
clamontagne@cheo.on.ca