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Marian Wilson, PhD Candidate, MPH, RN-BCSeptember 2012

No conflicts of interestFunded by

Washington State Life Sciences Discovery Fund

(Grant LSDF 08-02, Dr. John Roll, PI)

Washington State UniversityKootenai Health

Recognize the gaps in care for chronic pain in ED patients

Share pilot data on pain interference and depression among patients recruited to a web-based intervention

Strategize on closing the gaps to reduce recidivism, adverse effects of opioids, and psychological sequella for ED patients with chronic pain

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Policy, treatment, education and research gaps =>

Shortfalls in pain care. Relieving pain in America - A blueprint for transforming

prevention, care, education, and research,Institute of Medicine, 2011

The annual U.S. cost is $600 billion.On any given day, an estimated116 million U.S. adults are affected. (IOM, 2011)

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Personal losses◦ Work productivity, social roles, mental and

physical functioning (IOM, 2011)

Costs◦ Leading reason for ED care◦ 80% of all physician visits attributed to pain

(Gatchel et al., 2007)

CDC, 2011

Enough prescribed to medicate every American adult around-the-clock for one month (2010).

Second to marijuana as most abused drug.

400% increase in substance abuse treatment admissions for opioids since 1998.

0

2,000

4,000

6,000

8,000

10,000

12,000

1999 2007

2,900

11,500

Number of deaths

Unintentional deaths by opioids in U.S. 1999-2007

CDC, 2011

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Opioid medications for chronic pain remains controversial (Chou et al., 2009; Manchikanti, 2011; Stein, Reinecke, & Sorgatz, 2010)

No convincing evidence to support opioids as superior to nonopioids for long term treatment (Stein et al., 2010)

Behavioral and cognitive therapies -multidisciplinary pain care

Self-management of pain – “an essential part of clinical practice guidelines” for rehabilitation of chronic pain

(ICSI, 2011; Sanders, Harden, & Vincente, 2005)

Biomedical model = pain is a symptom that needs to be fixed.

What’s wrong with this model?

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Considers emotional, social, contextual, cognitive, cultural components of pain.

Psychology

Biology

Psychology

Sociology

Nurses◦ Overwhelmed & frustrated◦ No time for comprehensive

pain assessments◦ Poor access to health records◦ No follow up

Patients◦ Accessibility◦ Convenience◦ Dissatisfaction with primary

care provider

(Bergman, 2011;Dixon & Fry, 2011)

40% of all ED visits for pain attributed to chronic pain (Todd, Cowan, Kelly, & Homel, 2010).

50% of patients report not satisfied with the pain care they received; 40% do not have a positive change in pain level (Downey & Zun, 2010).

47% reported that their ED visit was “poor,” “terrible,” or “the worst experience of my life” (Todd, Cowan, & Kelly, 2006).

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Follow up calls on 500 ED pain patients found:

◦ 75% thought they needed more information to manage their symptoms

◦ 50% report receiving any information or referrals (Todd et al., 2010).

Stigmatizing labels

“frequent flyers” “drug-seekers” “addicts”

Pseudoaddiction

Reduce ED visits

◦ One pharmacy/One provider◦ Case management◦ Therapeutic contracts◦ Pain care management programs◦ Screen, Brief Intervention, Refer, Treat

(SBIRT) – SAMHSA.gov

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Coeur d’Alene,Idaho

246-bed

Not-for-profit, district hospital

ANCC MagnetDesignation

ED visits 50,000/yr

A retrospective study to examine one program’s effectiveness (Masterson & Wilson, 2010)

Primary interventions◦ Narcotic restriction (65%)◦ Referral to primary care (58%)◦ Initiate non-narcotic treatment regimen (57%)◦ Implement 1 pharmacy/1 provider restriction (23%)◦ Chemical dependency treatment (17%).

Mean annual ED visitspre 27.5 (SD 43.61)Range 3 - 311

Mean annual ED visits post 6.3 (SD 6.98)Range 0 - 38

Paired t-test p < .0001

N = 134

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Self-management programs demonstrate improved outcomes in specific pain populations.

Few studies test self-management interventions for the broader population of CNCP.

(Lorig et al., 2008; Macea et al., 2010; McGillion et al., 2008)

Social Cognitive Theory -

Self-efficacyConfidence in controlling

pain experiences can have positive impact on physical and psychological functioning

(Gatchel et al., 2007)

Albert Bandura

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Pain is a complex multidimensional experience

Patient can become expert in managing pain through self-initiated techniques

Monitor thoughts, feelings, catastrophizing

(Turk, 2004)

Goal-setting: Adopt new behaviors

Coping:Building confidence,

self-efficacy

Cognitions:Address thoughts &

feelings

Group persuasion:Social support /QOL

Education:Adherence

The tasks individuals must undertake to live with chronic health conditions.

(Lorig & Holman, 2003)

DeLeo, 2006

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The future of pain research lies in the brain!

Brain receives pain message

Sense and emotion interplay in thalamus

Awareness occurs Triggers mood,

alertness

Most patients receive pharmacological interventions -- biomedical model

Effective alternatives following a biopsychosocial model are not widely accessible Particularly in rural and lower SES populations Rare in ED settings, or routine primary care

Does an Internet-based self management program for chronic disease affect pain

ratings among ED patients with chronic pain?

(Wilson et al., 2011)

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Design Prospective, longitudinal, randomized

controlled pretest-posttest design

Treatment group trialing 6-week Chronic Disease Self Management Program (CDSMP) versus treatment as usual (TAU) wait-list group

Adult ED patients with chronic pain & treatment with opioids

◦ Eligibility: No planned surgery or current counseling ◦ Internet access, English-literate

• During ED visit or phone after encounter

ED Case manager/RN invites

• Mail in or at ED visit• Phone introduction to researchersInformed consent

• Free access to chronic disease self-management program with bookIncentives

• Email prompts Communications

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1. Baseline measurements via secure computer survey system

2. Treatment group receives program via web link

3. Both groups measured after 6 weeks

4. Wait list offered use of program

Pain intensity + Pain interference

Guided by IMMPACT Consensus Statement: Initiative on Methods, Measurement, and Pain

Assessment in Clinical Trials (Dworkin et al., 2005)

Brief Pain Inventory (BPI)

Activity Affect

Recognizes pain as a multidimensional experience

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Depressive symptomsPersonal Health Questionnaire Depression Scale (PHQ-9)

Patient’s perceived clinical improvementPatient Global Impression of Change (PGIC)

Distress caused by illnessHealth Distress

Subjective measure of overall health Self-rated Health

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RECRUITMENT130 patients eligible and approached

110 (84%) expressed interest

52 individuals (47%) completed and returned informed consent

22 (42%) completed baseline surveyRandomized

11 wait list group

9 post-tests

11 treatment group

2 post-tests

1 completed CDSMP

Female 68% (15) Mean age 41.4 (SD = 8.8) range 26-54 4 rural zip codes◦ 1 had no computer at home (library access)

Most common pain diagnosis◦ Fibromyalgia 27.3%◦ Migraines 27.3%◦ Back pain 22.7%◦ Arthritis 13.6%◦ Neck pain 9.0%

Pain interference exceeds pain intensity

No significant change in scores among those who complete post-test

5.967.52

0

2

4

6

8

10

Pain intensity Paininterference

BPI Mean

Mean

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Major depressive disorder should be considered for 54% (n = 12)

45% ( n= 10) had self harm thoughts

Depression significantly increased over time (t = -5.85, df = 9; P < 0.001).

PHQ-9 mean 16.86(SD 6.46)

>14 moderately severe depression

20.6

13.8

0 10 20 30

Posttest

Pretest

Mean PHQ-9 Scores

n = 11

Self-rated Health ◦ 50% rated themselves as “poor”

Health Distress ◦ Higher scores = more distress◦ Mean score 3.93 (SD = 0.89) on 0-

5 scale

Patient Global Impression of Change ◦ Score 5-7 = favorable change since

beginning treatment◦ No study participants scored higher

than a 4

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Positive significant relationships were detected between BPI pain severity & pain interference(r = .59*) Self-rated health & BPI interference (r= .57*)

and activity (r = .65*)

BPI pain interference/affect & PHQ-9 depression scores -> not significantly related

Small sample size, high attrition

Self-reports: subjective, changeable nature of pain

Between-group differences not analyzed due to low level of program engagement

Depression scores align with prior studies Co-exists with chronic pain Rarely detected in ED setting Screen, treat and refer recommended –

implementation?

Pain interference may offer clues Add affective assessments Address functional limitations BPI -> simple brief tool Consider depression-specific tool Self-rated health

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Prescribing opioids as sole solution presents risks, promotes recidivism

Pain management programs may be missing opportunities

Internet-based surveys can assess post-ED status, track pain/mood

More strategies needed for engagement with Internet-based self-management programs

Can self-management increase use of non-pharmaceutical pain interventions among opioidusers?

Can Internet-based programs reach diverse populations and increase access to cognitive and behavioral approaches to pain management?

Do multidimensional pain assessments using validated tools improve pain care?

Does recognition of depression improve quality of life and decrease health care utilization among patients with chronic pain?

Treating pain within a biopsychosocialframework considers the complex interaction of physical, cognitive, emotional, behavioral, and social factors.

To advance the science on self-management interventions, patients with chronic pain must engage in programs and give feedback.

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Bergman, C. (2011). Emergency nurses’ perceived barriers to demonstrating caring when managing adult patients’ pain. Journal of Emergency Nursing. Advance online publication. doi 10.1016/j.jen.2010.09.017

Centers for Disease Control and Prevention (CDC). (2011). Vital signs: overdoses of prescription opioid pain relievers - United States, 1999-2008. Morbidity and Mortality Weekly Report, 60(43), 1487-1492.

Chou, R., Fanciullo, G. J., Fine, P. G., Miaskowski, C., Passik, S. D., Portenoy, R. K. (2009). Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. Pain, 10(2), 131-46.

DeLeo, J. (2006). Basic science of pain. The Journal of Bone and Joint Surgery, 88-A(S2), 58- 62.

Dixon, W., & Fry, K. (2011). Pain recidivists in the emergency department. Journal of Emergency Nursing. Advance online publication. doi: 10.1016/j.jen.2010.10.008

Downey, L. A., & Zun, L. S. (2010). Pain management in the emergency department and its relationship to patient satisfaction. Journal of Emergencies, Trauma, and Shock, 3, 326-30.

Dworkin, R. H., Turk, D. C., Farrar, J. T., Haythornthwaite, J. A., Jensen, M. P., Katz, N. P.,… Witter, J. (2005). Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain, 113, 9-19.

Fishbain, D., Cole, B., Lewis, J., Rossomoff, H., & Rosomoff, R. (2008). What percentage of chronic nonmalignant pain patients exposed to chronic opioidanalgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Medicine, 9(4), 444-459. doi:10.111/j.1526-4637.2007.00370.x

Foster, G., Taylor, S. J. C., Eldridge, S. E., Ramsay, J., Griffiths, C. J. (2007). Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database of Systematic Reviews, 4. Art. No.: CD005108. DOI: 10.1002/14651858.CD005108.pub2

Gatchel, R., Peng, Y. B., Peters, M. L., Fuchs, P., & Turk, D. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624.

Glombiewski, J. A., Hartwich-Tersek, J., & Rief, W. (2010). Depression in chronic back pain patients: prediction of pain intensity and pain disability in cognitive-behavioral treatment. Psychosomatics, 51, 130-136. doi:10.1176/appi.psy.51.2.130

Institute for Clinical Systems Improvement (ICSI). (2011). Pain, chronic; Assessment and management of (guideline). Retrieved from http://www.icsi.org/guidelines

Institute of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. National Academies of Sciences. Retrieved from http://www.nap.edu/catalog.php?record_id=13172

Lorig, K., & Holman, H. (2003). Self-management education: history, definitions, outcomes and mechanisms. Annals of Behavioral Medicine, 26, 1–7.

Lorig, K., Ritter, P., Laurent, D., & Plant, K. (2008). The Internet-based arthritis self-management program: A one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis & Rheumatism, 59(7), 1009–1017.

Macea, D. D., Gajos, K., Calil, Y. A., & Fregni, F. (2010). The efficacy of web-based cognitive behavioral interventions for chronic pain: A systematic and meta-analysis. The Journal of Pain, 11(10), 917-929.

Manchikanti, L., Ailinani, H., Koyyalagunta, D., Datta, S. Singh, V., Eriator, I.,… Christo, P. (2011). A systematic review of randomized trials of long-term opioidmanagement for chronic non-cancer pain. Pain Physician, 14, 91-121

Masterson, B., & Wilson, M. (2011). Pain care management in the emergency department: A retrospective study to examine one program’s effectiveness. Journal of Emergency Nursing. Advance online publication available July 18, 2011.

McGillion, M.H., Watt-Watson, J. Stevens, B., LeFort, S.M., Coyte, P., Graham, A. (2008). Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain. Journal of Pain and Symptom Management,36(2).

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Sanders, S., Harden, R. N., Vicente, P. J. (2005). Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic nonmalignant pain syndrome patients. Pain Practice, 5(4), 303-315. doi:10.1111/j.1533-2500.2005.00033.x

Stein, C., Reinecke, H., & Sorgatz, H. (2010). Opioid use in chronic noncancerpain: guidelines revisited. Current Opinion in Anesthesiology, 23, 598-601.

Todd, K., Cowan, P., Kelly, N. (2006). Pain in the emergency department: an online survey of patient experience. Journal of Pain, 7(S), S61.

Todd, K., Cowan, P., Kelly, N., & Homel, P. (2010). Chronic or recurrent pain in the emergency department: national telephone survey of patient experience. Western Journal of Emergency Medicine, 11(5), 408-415.

Turk, D. (2004). Forward. In Thorn, B., Cognitive therapy for chronic pain: A step-by-step guide. (pp.vii-xi ). New York, NY: Guilford.

Wilson, M. (2011). Integrating the concept of pain interference into pain management. Pain Management Nursing. Advance online publication November 9, 2011.

Wilson, M., Roll, J., Pritchard, P., Masterson, B., Howell, D., & Barbosa-Leiker, C. Depression and pain interference among emergency department chronic pain patients. Poster presentation, Western Institute of Nursing’s Annual Communicating Nursing Research Conference, April, 2012.

Contact

Marian Wilson, MPH, RN-BC mwilson@kmc.org