Doc, I’ve Got This Pain

Steven M. Moskowitz, MDSenior Medical Director, Paradigm

Objective assessment and criteria

Careful Selection

Avoid trial and error

Measure effectiveness

Withdraw treatments that are not effective

Perspective and context

Key Take-Home Lessons on Chronic Pain

By the end of this presentation, you should understand the importance of systematic management by physicians

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$100 billion estimated annual cost in the US of health care, lost income and lost productivity due to chronic pain according to the NIH1

76 million Americans suffer from chronic pain according to the NIH1

26% of Americans age 20 years and older—an estimated 76.5 million Americans—suffer from “chronic pain”

80% of physician office visits due to pain4

Pain medications are the 2nd most commonly prescribed drugs in the US5

Generic Vicodin is top medication prescribed

Chronic Pain Remains a Chronic Problem

Despite innovation, chronic pain persists as one of the most chronic problems in the US.

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Sources: 1. NIH Guide: New directions in Pain Research (National Institutes of Health, September 4, 1988); 2. Flash Report (Workers Compensation Research Institute, August 2007); 3. Pain and Absenteeism in the Workplace (Ortho McNeil Pharmaceuticals 1997); 4.Koch, H. “The management of chronic pain in office-based ambulatory care: National Ambulatory Medical Care Survey (Advance Data from Vital and Health Statistics, No. 123, DHHS Publication No. PHS 86-1250); 5.Schappert, S.M. “Ambulatory care visits to physicians offices, hospital outpatient departments and emergency departments”: United States, 1996. 6. (Turk, D.C., Okifuji, A., Kalauokalani, D. Clinical outcome and economic evaluation of multi-disciplinary pain centers. A.R. Block, E.F. Kremer, and E. Fernandez)

■ 14% of claims and 11% of payments are due to chronic pain1

■ 50 million work days are lost in the US due to chronic pain2

■ Treatment statistics tend to be worse for worker’s compensation patients

■ 20% of workers’ compensation medical costs of fully developed claims are spent on prescription drugs; narcotics account for 34% of this spend

■ Admission rates for abuse of opiates other than heroin—including prescription painkillers—rose by 345% from 1998-2008

■ 120,000 Americans a year go to the ER after overdosing on opioid painkillers3

Chronic Pain and Drug Use

Chronic pain is a persistent problem in workers compensation, and with it are significant drug-related issues.

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1. According to the Workers’ Compensation Research Institute (WCRI) within the 14 states they rate.2. According to a study conducted by Ortho-McNeil Pharmaceutical.3. According to Laxmaiah Manchikanti, CEO for the American Society of Interventional Pain Physicians.

■ 70-80% lifetime incidence. Up to 10% incidence per year

■ The CDC 2010 reported that 30% of people had LBP in the prior 3 months1.

• Ages 18-24 (21%), 25-44 (27%), 45-54 (32%), 55-64 (33%), 65-74 (30%), >75 (34%)

• Neck pain: less frequent by about 40-50%

• Joint pain: Age 18-44 (21%), 45-64 (42%)

• Hospice care patients symptoms at last hospice visit before death: Pain 33.3%

■ 250,000 lumbar surgeries are performed annually

• 2006-2007 rates have kept steady since 1996-97 for 45-64 year old group, increased by 67% for those over 65

• For comparison, knee replacement has increased by over 100% and total hip replacement by just under 100%

1. CDC Health, United States 2020

Back Pain

A Common Symptom

Back Pain, All Pain, Is Often A Lifestyle Condition

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■ Having back surgery is a major risk factor for having more back surgery

– 18.9% cumulative risk of additional back surgery in 9 years

• Reoperations after lumbar disc surgery: a population-based study of regional and interspecialty variations1

– Patients with one reoperation after lumbar discectomy had a 25.1% cumulative risk of further spinal surgery in a 10-year follow-up

• Risk of multiple reoperations after lumbar discectomy: a population-based study2

■ Most benefits of surgery, for those who benefit from surgery, last 1-2 years compared to those not having surgery

1. Spine, 2000 Jun 15;25(12):1500-8.2. Spine, 2003 Mar 15;28(6):621-7.

Back Pain

Back surgery is not a wise “last resort”

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Chronic Pain Management Can Seem Chaotic

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Radiculopathy

Opioids

CRPS

Facet arthropathy

SIJ

Injections

Symptom magnification

Spinal Cord Stimulator

Fear Avoidance

The power of the physician’s pen

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Opioids CRPSEpidural Steroid Injections SIJ Injections??? Spinal Cord stimulator RadiculopathyAny other new and exciting treatments?

By writing prescriptions without investigating, relying on a trial-and-

error method without a comprehensive plan, and using the

newest (most expensive!) treatments that haven’t been proven, physicians can contribute to a cycle of chronic

pain and prescription overuse

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A Systematic Health Management Approach To Chronic Pain

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What is Pain?

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What is Pain?

Pain Perception

Nociception

Somatosensory System

Pain Neurological Interpretation

Neuromodulation

Cognitive Interpretation

Emotional Influence and Response

What is Pain?

The pain experience is both individual and complicated

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Nociceptive PainPain sensation from

damage, inflammation

Neuropathic Pain

Pain from nerve compression, damage

Central MechanismsComplex central nervous system interpretation,

regulation, sensitization

Secondary impairmentsMyofascial pain,

stiffness, deconditioning,

debilitation

Psychosocial Component

Factors that impact illness perception, adaptive coping,

compliance

Components of Clinical Pain

The Pain Experience

Chronic Pain is Not Acute Pain

Acute pain typically resolves within a certain time frame. Pain lasting beyond this time is what we refer to as chronic pain. Treatment should differ from acute.

14The clinical and claims approaches differ

■ Acute pain

■ Acute pain with psychological dysfunction

■ Chronic pain

■ Chronic Pain with psychological dysfunction

■ Chronic pain syndrome

Is All Chronic Pain The Same?

Knowing the terminology can help.

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Chronic Pain

Chronic pain is a syndrome that emerges at variable speed.

PAINPAIN PAINPAIN

insomnia

atrophy

fear of movement

PAINPAIN

depressionatrophy

insomnia

weight gain

medical issues

life rolesaddiction

Acute Pain(0-3 months)

Transitional(3-6 months)

Chronic Pain Syndrome(Greater than 6 months)

■ MALADAPTIVE COPING behavior– Symptom magnification – Inconsistent performance– Fear avoidance– Drug seeking– Catastrophising, somatization…

■ Pre-morbid personality traits or psychological problems

■ Concurrent psych issues – Axis I (e.g. depression)or Axis II (e.g. personality disorders)

■ Somatoform disorders (Axis I or II functional)

■ Stress diathesis model

Psychological Factors

Some of the more common psychological factors have to do with coping

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.

Biomedical Model

■ Definition-search for a pain generator to extinguish it

■ Focus

■ Potential Dangers

– Over-reading basic science

– Trial and error

– Over-reading of clinical research

– Loss of “carefully selected” criteria

– Accumulation of failed treatments

– Polypharmacy

Biopsychosocial Model

■ Definition-pain complaint and experience in context of beliefs, fears, self limitation, secondary gains and losses

■ Focus

■ Potential Dangers

– Forgetting the Biological

– Missing a clinical cue

– Getting too deep in patient’s lifelong issues

– Becoming another dependency

Not All “Pain Management” Philosophy Is The Same

Some styles of pain management can make a patient worse

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Maladaptive Cycle in Entrenched Chronic Pain

Unrealistic expectations Illness conviction Catastrophizing Fear avoidance Quick fix seeking

Quick fixes Trial and error approach Lack of objective measures Poly-pharmacy Escalating interventions

If clinicians misinterpret pain behaviors as representing pain generators they increase treatment, thereby reinforcing maladaptive behavior.

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Patient

Provider

Patient

Provider

Patient Maladaptive Belief

Physician Maladaptive Response

Impact

Catastrophizing, fear avoidance, symptom magnification

Misdiagnosis/over-diagnosis, escalating interventions, polypharmacy

Worse illness conviction due to failure, iatrogenic disability

(Remember Occam’s Razor)

Pain is all physical All biomedical interventions Overtreat, side effects, iatrogenic illness, prolonged disability

Poorer results on interventional

Lack of insight: my pain rating is 15/10

Lack of objective measures Poor differentiation of helpful and non-helpful interventions

Desire for quick fix Quick fix offer, trial and error approach

Lack of investment in things that help

The beliefs and actions of patient and provider interact

Sometimes they are not productive

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Injured Worker Symptoms out of proportion to objective

findings-extremely high pain complaint

Catastrophizing behavior

Inordinate disability

New complaints

Maladaptive coping/adjustment disorder

Inconsistent findings or behavior, situational

Lack of significant benefit from any treatment

Medication seeking

Providers Ever-changing diagnosis

Lack of objective measures

Adding new body parts

Trial and error approach

Escalating polypharmacy, particularly opioids

Excessive focus on bio and ignoring maladaptive coping

Red Flags for Maladaptive Pain Cycle

These may initially be easy to miss.

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Factors Perpetuating Ineffective Care

How can you work with providers to help turn it around?

Concepts Actions

■ Clarify the diagnosis

■ Radiculopathy, discogenic pain, facet arthropathy, SIJ syndrome, failed back syndrome

■ Coordinate appropriate care

■ Manage behavior, perception, expectations

What is a systematic approach

Biopsychosocial Model

A methodical approach to chronic pain

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The Case of the 13 out of 10 pain…

Red Flags: The Case of “11 out of 10” Leg Pain

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13 out of 10!

What is your pain rating?

How are the medications working?

The Oxycontin is great, but I need more.

How was that epidural steroid injection?

I felt great for two days!

We’d better get you an MRI and schedule an ESI and some facet injections.

Doc, can I have a refill of my Oxycontin? I need a higher dose. And can I get validated parking

for my truck?

Clarify the Diagnosis

Clinical assessment

– Objective criteria for diagnosis

Criteria for diagnostic testing

– Clear reasons for this test

Careful interpretation (Danger)

– Common occurrence of incidental findings

Behavioral factors

– Catastrophizing, fear avoidance, self efficacy, secondary gain

Coordinated and Appropriate Treatment

Treatment criteria

– Carefully selected

Treatment effectiveness measures

– Subjective and objective

Clear intervention criteria

– Increase or discontinue

Behavioral interventions

– Set realistic expectations, accountability, perspective

Biopsychosocial Approach to Procedures

Be systematic

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■ MD: I read your record and see that you are 43 years old, you are a carpenter and your shoulder has been hurting for 3 years. Is that correct

■ Patient: Yes it is horrible. When I was in Cabo last week, it hurt the whole time. I could hardly use it.

■ MD: I noticed you have quite a tan. Where is the pain exactly?

■ It starts at my shoulder and goes down my arm to here (he points to his wrist).

■ I see you are on the Fenatyl patch, does it help?

■ Patient: It takes the edge off. The OxyContin helps more.

■ MD: Are you working? If not, I bet you want to get back to work.

■ Patient: I am on Disability (Social Secruity).

■ MD does examination: calls out: normal muscle tone, decreased ROM, no sensory loss. I see your old MRI showed bulging discs.

■ MD: I think you may have a pinched nerve. Lets get a new MRI of your neck and an EMG. I recommend we get a UDS. I would like to schedule an epidural steroid. Here is some information on SCS to look at also.

■ Patient: Doc, UDS? What are you saying?

Case 2: New patient, Mr. Spinatus; Accepted shoulder claim

Doc, I can’t lift my shoulder!

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The Case of the Disabled Beachcomber…

New Patient: Accepted Shoulder Claim

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It’s horrible! When I was in Cabo last week, it hurt the whole time. I could hardly use it.

You are 43 years old, a carpenter, and your shoulder has been hurting for 3 years. Is that correct?

I noticed your tan. Where is the pain exactly?

It starts at my shoulder, then goes to my wrist.

I see you are on the Fenatyl patch, does it help?

It takes the edge off. The OxyContin helps more.

Are you working? If not, I bet you want to get back to work.

I am on Disability.

I think you may have a pinched nerve. Let’s get a new MRI of your neck and an EMG. I recommend we get a UDS and schedule an epidural steroid.

Clarify the Diagnosis

Clinical assessment

– Objective criteria for diagnosis

Criteria for diagnostic testing

– Clear reasons for this test

Careful interpretation (Danger)

– Common occurrence of incidental findings

Behavioral factors

– Catastrophizing, fear avoidance, self efficacy, secondary gain

Coordinated and Appropriate Treatment

Treatment criteria

– Carefully selected

Treatment effectiveness measures

– Subjective and objective

Clear intervention criteria

– Increase or discontinue

Behavioral interventions

– Set realistic expectations, accountability, perspective

Biopsychosocial Approach to Procedures

Be systematic

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Chronic Pain Management Should Not Be Chaotic

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■ Appropriate medications and treatments

A coordinated plan best serves the patient’s needs.

Inappropriatetreatments

Comprehensive, Individual Plan

Understanding behavioral factors and cognitive

behavioral approach

Clarify the diagnosis (biopsychosocial assessment)■ Clarify patient symptoms, location and circumstances■ Administer pain questionnaires ■ Clarify the criteria for a given diagnosis■ Identify early behavioral red flags, psychosocial factors

Monitor medication use ■ Query all new medications ■ Compare with existing medications for redundancy and interactions■ Educate patient on potential and existing side effects and toxicity■ Assure proper monitoring is in place, use MED calculator■ Coach patient on outcome measurement and realistic expectations

Monitor all invasive intervention■ Help determine if patient is the appropriate candidate■ Assist patient in formulating questions regarding their goal, likely effectiveness and risks■ Coach patient on outcome measurement and realistic expectations

Help identify more effective and holistic chronic pain treatment options■ Non-pharmacological care■ Cognitive behavioral therapies■ Interdisciplinary CPMP ■ Self-management

The Role of Pain Management and Case Management

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What is old

■ Discograms

■ Opioids with no ceiling dose

■ Intradiscal electrotherapy

■ Trial and error

■ Physician non-accountability

■ Therapeutic exercise-an old but goody

What is new

■ Opioids: high dose short-term opioids, stronger opioids, state implementation of prescription monitoring programs

■ New molecules

■ Analgesics and neuromodulators

■ Prialt, Ketamine

■ Topical agents

■ Laser back surgery, new electrical stimulation devices , HBOT!

■ Rehabilitation: resurgence of CBT, functional restoration, patient education and awareness

■ A greater emphasis on outcomes

■ Regulatory: guidelines, state pharmacy management programs

The Chronic Pain Toolbox

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Common side effects and complications

■ Dependence, addiction, misuse and death

■ OIH

■ Hormonal disorders

■ Urinary dysfunction

■ Constipation

■ Nausea

■ Fatigue

■ Diversion

Mitigation strategies

■ Universal precautions

■ Dosage guidelines

■ Morphine equivalent dose

■ State prescription monitoring program

The Challenges of Opioids

Are narcotics overused?

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■ Make a Diagnosis With Appropriate Differential following a comprehensive evaluation.

■ Psychological Assessment, Including Risk of Addictive Disorders and stratification.

■ Informed Consent.

■ Treatment Agreement.*

■ Pre- or Post Intervention Assessment of Pain Level and Function.

■ Appropriate Trial of Opioid Therapy With or Without Adjunctive Medication.

■ Reassessment of Pain Score and Level of Function.

■ Regularly Assess the "A's" of Pain Medicine (analgesia, activities of daily living, adverse side effects, and aberrant drug-taking behaviors); "adherence" and "affect (observed mood) might also be added.

■ Urine Toxicology*

■ Periodically Review Pain Diagnosis and Comorbid Conditions, Including Addictive Disorders.

■ Documentation.

Universal Precautions

Universal Precautions in Pain Medicine, which experts in pain medicine recommend be used with all pain patients. Authors: Gourlay DL, Heit HA, Almahrezi A. 2005.

Source: Pain Medicine proprietary and confidential

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■ Restoration of function: the concept

■ Rehabilitation should be the goal of all pain management interventions = return to optimal function

■ What is function? (World Health Organization, International Classification of Function)

■ Studies repeatedly show that when you uncouple pain and function, function can dramatically improve

■ Objective measures

■ Measurement that is not subjective, not dependent on effort

■ Blood pressure, temperature, pulse, range of motion, calf measurement, reflexes, strength, gait

■ Functional measures examples (ODG 2012)

– Work Functions and/or Activities of Daily Living, Self Report of Disability (e.g., walking, driving, keyboard or lifting tolerance, Oswestry, pain scales, return-to-work, etc.)

– Physical Impairments (e.g., joint ROM, muscle flexibility, strength, or endurance deficits)

– Approach to Self-Care and Education (e.g., reduced reliance on other treatments, modalities, or medications, such as reduced use of painkillers)

Restoration of Function

Disturbance of function, not pain, is what ultimately causes disability

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■ Rush to market promoted by for-profit drug and technology companies

■ FDA approval does not = effective or safe

■ To get FDA approval, you only need to submit 2 studies showing it is better than placebo, no matter how many studies show it is not (1)

■ Rampant off label use; lack of careful selection

■ Shift in physician training opportunities to procedural opportunities-glut of providers

■ Physical Medicine and Rehabilitation experience

■ Direct marketing to patients

■ Lack of regulation seen in other areas of medicine

■ Compare to acute care, core measures (Diabetes management, CHF management)

■ Lack of outcome measures or expectations (acute care cardiac success rates, CEA, complication rates)

The Business of Chronic Pain

Buyer beware

361. The New York Review of Books, The Epidemic of Mental Illness: Why?; June 23, 2011; Marcia Angell

■ What happens when the usual adjudication process does not work

■ The injured worker gets opposite messages from doctor than from UR

■ The injured worker becomes more and more alienated; iatrogenic disability

■ Red flags

■ Delayed return to work

■ Getting worse rather than better

■ Crescendo of requests

■ Anger and alienation

■ Solutions

■ Systematic approach

■ Medical case management action team

■ A collaborative approach

■ Understand the bigger picture: biopsychosocial model

■ Seek first to understand

■ Get everyone on the same page

When the claims approach does not work…

Identify when the usual process is allowing care to splinter

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Pain Management Philosophy

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Expert, effective pain management involves a biopsychosocial, evidence-based foundation.

Peer and Case Management Experts

Centers of Excellence

Systematic Care Management SM

Clarification of Diagnosis

Coordination of Care

Pain Behavior Intervention

Analytics

Accurate diagnosis Evidence Supported Care Less Reliance

Physicians Can BeDeceived

“Actors were identified as the standardized patients around 10% of the time.”

Physicians Being Deceived; Beth Jung MD, Pain Medicine Volume 8, Number 5, 2007

Objective assessment and criteria

Careful Selection

Avoid trial and error

Measure effectiveness

Withdraw treatments that are not effective

Perspective and context

■ ROM, strength, sensation, movement, gait…

■ Is this test or treatment proven appropriate to this type of patient in this circumstance

■ Just “trying” is a set up for failure, placebo

■ There should be a meaningful functional measure

Key Take-Home Lessons on Chronic Pain

By the end of this presentation, you should understand the importance systematic management

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