Pain ManagementPresentation by: Harold Gottlieb, Ph.D

DISCLOSURES

Dr. Harold Gottlieb has no relationship with the manufacturer of any commercial products and/or provider of commercial services

Definition of pain

The International Association for the Study of Pain (IASP) defines pain as:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

“Whatever the experienced person says it is, existing whenever he or she says it does” (JCAHO, and NPC, 2001, pg 4)..

The COMPLEXITY OF CHRONIC PAIN

More than 87% of persons with chronic pain present at least one other comorbid pain disorder (69%), functional disorder (55%), or psychiatric disorder. (Von Korff et al., 2005)

Significant functional disability drives medical costs upward. (Blyth et al., 2001)

Medications contribute substantially: 312 million prescriptions for analgesics (137 million for opioids) are written each year = $62.5 billion annually. (Merck Pharmaceutical, 2002)

Surgery: More than 317,000 lumbar surgeries are performed each year (primarily for pain) at an average cost of $15,000.

Total Cost = >$4.7 billion annually.

Pain vs. suffering

Pain Behavior

Suffering

Pain

Nociception

Challenges to the sensory-physiological model• Patients with objectively determined, equivalent degrees

and types of tissue pathology vary widely in their reports of pain severity.

• Asymptomatic individuals often reveal objective radiographic evidence of structural abnormalities.

• Patients with minimal objective physical pathology often report intense pain.

• Surgical procedures designed to inhibit symptoms by severing neural pathways believed to be subserving the reported pain may fail to alleviate pain.

• Pharmacological agents designed to alleviate pain may have widely differing effects.

• Patients with objectively equivalent degrees of tissue pathology who are treated with identical interventions often respond in widely disparate ways.

• Physical impairment, physical functioning, pain report, disability, and response to rehabilitation appear to be only modestly correlated.

PAIN EXPERIENCE

• Perception and manifestation of PAIN• It includes:

- Thoughts- Feelings- Reactions- Expectations- Past experience(s) associated with

pain

• WW2 soldiers with serious wounds complained of less pain then did post operative patients at Massachusetts General Hospital & requested less morphing.

• Hypothesis: the soldiers pain was alleviated by survival of combat and the knowledge that they could now spend weeks or months in safety and relative comfort while they recovered.

• The hospital patients, however, had been removed from their home environment and now faced an extended period of illness and the fear of possible complications.

• Challenged stimulus response views of pain. ▫ Emphasize role of meaning, interpretation context culture.

Contextual Examples

Just as “my pain” belongs in a unique way only to me, so I am utterly alone without it. I cannot share it. I have no doubt about the reality of the pain experience, but I cannot tell anybody what I experience. I surmise that others have “their” pains, even though I cannot perceive what they mean when they tell me about them. I am certain about the existence of their pain only in the sense that I am certain of my compassion for them. And yet, the deeper my compassion, the deeper my certitude about the other person’s utter loneliness in relation to his experience.

Ivan Illich (1976)

Subjectivity Objectivity Debate

Is Cartesian Model Still Alive?

The Challenge of Pain•Over time, negative thoughts and its

beliefs about pain, and behaviors related to pain can become very resistant to change.

Epiphenomena1.Substance use disorders or varying severity with their attendant

central nervous system side effects2.Multilple operations or pharmacological treatments with heir own

morbid side effects separate from those related in (1)3.Escalating physical incapacity secondary to pain, anticipated pain,

and fear that this increased pain is a signal of increasing bodily harm and damage

4.Increasing hopelessness and helplessness as increasing dysphoria does not give way in the face of mounting numbers of “newer” or different therapies

5.Conflicts with medical care delivery personnel (doctors, nurses, therapists, and technicians)

6.Interpersonal conflict with significant others7.Unpleasant and lasting mood and affect changes8.Decrease in feelings of self-esteem, self-worth, and self-confidence9.Escalating psychosocial withdrawal and increased loss of

gratification from these interactional inputs10.Decreased ability to obtain pleasure from the life process,

contributing to profound demoralization and, at time, significant depression

Acute• Up to a few days’ duration• Mild or severe• Cause(s) unknown or known• Presume nociceptive stimulus• Sufferer expects relief based on medical

interventious; extended coping efforts not seen as necessary

• Physicians expects pain complaints to decrease with healing of affected tissues (e.g sunburn, toothache, and postsurgical pain)

Recurrent Acute (Intermittent)• Patient experiences variable pain-free intervals

• Presumed nociceptive (tissue-derived) in out from a pathological process (e.g migraines, sickle cell crisis, arthritis, primary trigeminal neuralgia, and myofacial pain)

• Physician expects continued therapeutic efforts to pay off

Ongoing Acute (Progressive)

•Continued nociceptive input (e.g., cancer)•Physicians willing to use potent narcotics•Patients often concerned about the effect

of analgesics on chemotherapy•Treated like acute pain by patients and

physicians

Acute Pain

•Symptoms of underlying problem•Damage to the System•Source is Easily identifiable•Time limited healing process•Analgesics or narcotics “may” be used

Prechronic

•A few days’ to a few months’ duration •Similar to acute, except not viewed as an

emergency •Known pathology

Chronic Benign (Persistent)

•Nonneoplastic (noncancerous)•About 6 months in duration•No known pathology or nociceptive input•Patient is apparently coping adequately,

had not made pain the center of his/her life

•Physicians feel they can establish a working relationship with these patients

Chronic Intractable Benign Pain Syndrome (CIBPS)•Duration of 1 year and up•Physicians view patients as difficult to

treat. Psychiatric referral are common•Patients show physical decline (usually

brought on by inactivity), psychological passivity (discouragement; depression), and excessive preoccupation with pain

•Familia reward for “invalid” status (secondary gain)

General Characteristics

•The chronic intractable benign pain syndrome (CIBPS) is defined as an ongoing problem with pain that:

1. Cannot be shown be causally related in the here and now with any active pathophysiologic or pathoanatomic process

2. Has a history of generally ineffective medical and surgical intervention in the pain problem

3. Has come to be accompanied by disturbed psychosocial functioning that includes the pain complaint and the epiphenomena that accompany it

The Chronic Treatment Trap

The Chronic Medication Trap

The “take it easy” Trap

The Chronic Resentment Trap

Biopsychological vs. Traditional claims/Disability Management Approach in the Insurance System

Biopsychological vs. Traditional claims/Disability Management Approach in the Insurance System Cont.

Biopsychological vs. Traditional claims/Disability Management Approach in the Insurance System Cont.

Biopsychological vs. Traditional claims/Disability Management Approach in the Insurance System Cont.

Secondary gain and Malingering in Pain

Secondary Gain

Secondary Losses Versus Secondary Gains

Secondary Losses Versus Secondary Gains

Examples of Tertiary Losses

The Functional Restoration program

Team Approach Communication and team work =

Critical! Mutual reinforcement of all team

goalsOperant Conditioning Model: Team works

to reinforce Well behaviors (movement, exercise,

reducing medication, attendance despite pain flare ups) vs.

Pain behaviors (medication increases, Bx displays of pain, bed rest, etc.).

The Functional Restoration Program

Patient Cure Thyself Designed to shift locus of control from external to internal.

We work to provide the patient with:o Tools that are directly accessible to the patient

▫E.g. exercise in the form of walking, strength training using their own body weight, self-release techniques, CBT for emotional and stress regulation, deep breathing for relaxation and pain reduction, an individualized plan for medication reduction/management.

o Consistent positive feedback and reinforcement of gains made

o Team meetings in which patient’s progress is presented to and discussed with them

The functional Restoration Program

4 weeks, Monday – Friday, 8:00 a.m. – 12:00 p.m.

Combination of CBT + PT + OT + Medical CBTo Cognitive restructuring (from catastrophic

and maladaptive to helpful and realistic thoughts)o Biofeedbacko Guided imagery, relaxation, meditationo Assertiveness trainingo Expressive writingo Mindfulnesso Psychoeducation

The Functional Restoration Program

Team Approach Communication and team work = Critical! Mutual reinforcement of all team goals

Operant Conditioning Model: Team works to reinforce Well behaviors (movement, exercise, reducing

medication, attendance despite pain flare ups) vs. Pain behaviors (medication increases, Bx displays of

pain, bed rest, etc.).

The Functional Restoration Family Day

Operant Conditioning Education Getting the family involved in Treatment Further family therapy if necessary

Relapse Prevention Patient is taught about relapse, what it is (discontinued

skills practice), how to either avoid it, or make it a short-term setback

Follow ups at 1, 3, 6, 12 month intervals to assess progress

Weekly emails

The Functional Restoration Program Physical Therapy

Increase functionality, flexibility, stamina, strength, etc. Teach self-release techniques Teaching patient’s to engage in individualized home exercise program

without supervision Reducing fear-avoidance associated with movement and pain

Occupational Therapy Educational (pain, injuries, etc.) Proper body mechanics Ergonomics

Medical Stabilization, reduction, or elimination of medication Education Powerful reinforcer

o Patient’s own responsibility in their health careo Proper utilization of the healthcare system

•

“Good Candidates” to Consider:Chronic painWillingness to reduce reliance on

medicationFailed some other modalitiesConcomitant depression or anxiety or

coping skill issuesAble to make time commitment (only 20

half-days)Medically-stable enough to participate

Success of CPP’s – functional restoration

2-Year up: 87% of the functional restoration treatment group was actively working at 2 years vs. 41% of non treatment comparison group. (mayer et al., 1987)

Twice as many of the comparison group members had additional spine surgery and unsettled workers compensation claims compared to the treatment group.

Comparison group: 5x higher rate of patient visits to healthcare providers and higher rates of re-injury.

Outcomes Continued-Pain and Quality of Life

Flor et al. 1992; Mayer & Gatchel, 1988; Tollison et al., 1985

CPP’s: 14% - 60% pain reduction, Average = 30%

Opioids: Average pain reduction of 30% (Turk et al. 2002)

Comparison of functional outcomes vs. Unimodal conventional medical care

Medical group: 35% increase in physical activity

CPP’s: 65% increase in physical activity (Flor et al. 1992)

Outcomes Continuedreturn to work rates (rtw)

A compilation of 18 studies:▫Conventional medical treatment

oRTW rates = 0 – 42%, Average = 27%▫CPP’s

oRTW rates = 29% - 86%, Average = 66%

Other studies show comparable numbers

Outcomes Continued- Healthcare utilization

> 33% reduction in pain-related visits in the HMO setting in the year following CPP completion (Caudill et al. 1991)

60% - 90% of CPP patients do not seek any additional therapy for pain within 1 year following treatment (Cairns et al. 1984; Seres et al. 1976: Tollison et al. 1985)

50% decline in pain-related clinic visits following CPP treatment. (Mayer et al 1987)

Surgery: CPP treated patients: 16% and 17% receive

subsequent surgical therapy and hospitalization (respectively) (Okifuji et al. 19999: Turk & Okifuji, 1998)

Conventionally treated patients: 50% undergo surgery or would be hospitalized (Simmons et al., 1988)

Annual medical costs following a CPP are reduced by 68% (Simmons et al., 1998)

Outcomes Continued Disability Claims

$43 billion is spent annually in the U.S. for disability compensation for back pain alone (Frymoyer et al., 1997)

Proportion of patients receiving disability significantly declined from 70% at program admission to 40% upon follow up (Painter et al., 1980)

75% of the cases were recommended for closure (Seres et al., 1976)

Majority of litigation was settled within 1 year (Mayer et al., 1985)

Outcomes Continued Pharmaceutical Use Medication costs for back pain alone = $5,000 - $10, 250 per

patient (De Lissovoy et al. 1997, Strauss, 2003)

Sale of analgesics in US: $8 billion in 2000 and expected to grow by 10% annually. (Marketdata enterprises, 1995)

2013 = $27.6 billion CPP = > 65% of patients discontinue their opiate medication for

at least 1 year (Tollison et al., 1985)

Opioid use for CPP participants: 69% at admission, 22% at 1 year follow up

Non-participants: 81%, 75% at one year follow up (Tollison et al., 1991)

Overall Cost Effectiveness Healthcare savings: $8,500 - $8,772 per patient, per year

following CPP treatment (Okifuji et al. 1999; Turk, 2002; Turk et al. 2002)

CPP saves $356,288 per person over the course of a lifetime compared with conventional medical therapy.

5 year follow up = progressive improvement Return to work, litigation settlement, pain rating,

activity, medication use, hospitalizations (McArthur et al. 1987)

Cost Effectiveness Fairbank et al. (2005): Spinal fusion vs. CPP with chronic

low pain patients (n = 349) Multi-center, randomized, controlled study.

24 month follow up: Comparing disability and pain levels Results: Both groups improved, with no evidence

that surgery produced more relief or greater increase in functioning than CPP group.

Rivero-Arias et al. (2005): 2 year follow up Average cost of surgery: $14,000 > $8,323 for the

CPP

Functional Restoration as PreventativeGatchel et al. (2003) Randomized, controlled study:Acute low back pain patients “high risk”Randomly assigned: Early FRP or TAUResults: FRP group displayed significantly fewer indexes of

chronic pain disability at 1 year follow up in areas of work, healthcare utilization, medication use, & self-reported pain variables.

FRP group less likely to be taking narcotic analgesic (odds ratio = 0.44)

FRP group less likely to be taking psychotropic medication (odds ratio = 0.24)

TAU group less likely to have returned to work (odds ratio = 0.55) Cost comparison: TAU group cost twice as much as the FRP group

over a 1 year period.

Ancillary Benefits to the Referring ProviderPatients get betterPatients are taught a new skill-set for dealing with

painPatients learn new communication skillsDepression and anxiety are reducedPatients almost across the board have significantly

reduced medication burden in just one month.Reinforce the mindset that opiated and medication

are not always the “answer”Patients who complete the program generally return

easier to treat in general.Increased revenue for the group

Relapse can generate the following consequences:• 1.)It can conform the patient’s and family’s initial belief in

the hopelessness of their pain-disease dilemma.• 2.)Relapse can serve as yet another conformation of the

legitimacy of the pain patient's disability.• 3.)Relapse can represent another failure of the health care

system and can particularly tarnish the reputation of the multidisciplinary pain center as a viable alternative pain management strategy.

• 4.)Relapse can provide disheartening results which can save as an impetus to the patient to initiate a search for more aggressive and perhaps controversial treatment.

• 5.)Relapse can add an additional financial and emotional burden to the patient’s family, third party payer and employer.

Culture Defined• Culture has been defined by Kemp (2005) as “…the

learned and shared beliefs, values, and lifeways of a designated or particular group that are generally transmitted inter-generationally and influence one’s thinking and action modes” (pg.44).

• Culture has the ability to shame attitudes and beliefs about health and illness. More specifically, it affects one’s openness to receiving support through healthcare services in addition to one’s health seeking behaviors (Lovering, 2006, pg. 390).

Culturally Sensitive Pain Assessment Tool*

• What do you call your pain? What namedo you give it?• Why do you think you have this pain?• What does your pain mean for your body?• How severe is it? Will it last a long or shorttime?• Do you have any fears about your pain?*Lasch, K. Culture, Pain and Culturally Sensitive Pain Car. Pain Management. Nursing. 2000, 1(3), p.19.

Culturally Sensitive Pain Assessment Tool*

• If so, what do you fear most about yourpain?• What are the chief problems that your paincause for you?• What kind of treatment do you think youshould receive? What are the mostimportant results you hope to receive fromthe treatment?Luth, K. Culture, Pain 100 Culturally Sensitive Pain Care. Pain Management NursIng, 2000, 1(3), p.19.

Culturally Sensitive Pain Assessment Tool*

• What cultural remedies have you tried to helpyou with your pain?• Have you seen a traditional healer for your pain?Do you want to?• Who, if anyone, in your family do you talk toabout your pain? What do they know? What doyou want them to know?• Do you have family and friends that help youbecause of your pain? Who helps you?

*Lasch, K. Culture, Pain and Culturally Sensative Pain Care. Pain Management. Nursing, 2000, 1(3),p.19.

Where are we?• Bonham (2001) reviewed numerous studies to identify racial

and ethnic differences related to pain treatment.

• Bonham’s review revealed that numerous studies have demonstrated the difference in pain presentation that are solely based on culture, race and ethnicity.

• Bonham called for future research to study actual clinical treatment or intervention for pain management in minorities.

• Ten years after Bonham’s study this area still requires further study, which led to the development of my evidence based culturally competent educational intervention and my research study.

Impact on Culture on Pain

•Over the course of human existence, a variety of beliefs evolved about the cause of pain.

•A common cultural belief is that pain derives from a supreme being as a form of punishment for one’s sins or misbehavior.

•Pain is viewed as “the soul’s experience of evolution” (Matelliano, 2003, p.1).

Impact of Culture of Pain• Pain is subjective. There for the perception of

pain and its severity is variable.

• Pain presentation may reflect personality or cultural variation that are not easily appreciated (McCarberg, 2008).

• Some patients are reluctant to discuss their pain because they fear it signals a worsening of their condition or takes attention away from their “real disease” (MCCarberg,2008).

Impact of Culture on Pain

•Others believe that pain is an inevitable or necessary part of their condition or that bearing pain may be admirable or benefical (McCarberg, 2008: Resnick, Rehm, Menard, 2001).

•Differences in personal conviction or cultural norms also affect the extent to which patients report pain and their expectation for pain relief (Fosnocht, Swanson & Barton, 2005).

African Americans

• Perceived as sign of illness or disease• Take pain medication only if experience pain• Believe in

- Suffering and pain is inevitable- Must be endured- High tolerance as a result of

spiritual andreligious foundation- Prayers and laying of hands- Faith is proportional to relief

Background• The evidence is overwhelming that AA patients

are less likely to receive analgesia for pain as per the recommended guidelines when compared to non-minorities.

• This is true in both oncology and non-oncology patient settings (Anderson, Green & Payne, 2009; Pletcher, et. al,Nguyen, Ugarte, Fuller, Hass & Portenoy, 2005; IOM, 2003; Bonham, 2001; Anderson, Mendoza, Valerro, et al, 2000; Cleeland, Gonin, Baez).

Background of the Problem• Minorities are disproportionately impacted with pain (IOM, 2003).

• American Indians and Alaska Natives have the highest incidence rates of LBP (Deyo,et al, 2002).

• African Americans are under-treated for pain (Anderson, Green & Payne, 2009; Pletcher, et al, 2008; IOM, 2003; Anderson, Mendoza, Velero, et al, 2000; Cleeland, Gonin, Baez, et at, 1997).

• The experience of pain is personal and is influenced by one’s cultural identity.

• The management of pain is multifaceted and when coupled with one’s cultural attitudes, beliefs and values, can further add to it complexity.

Cultural Components of Pain • Zborowski (1952) was one of the first to study

the cultural components of pain. He studied three cultures in New York: Jewish American, Italian American and Irish American.

• Zborowski (1952) found that Jewish and Italian Americans were very vocal with their pain but Irish Americans were less vocal and more accepting of the pain.

Cultural Differences in Pain Sensitivity

• To determine pain sensitivity across ethnic groups Rahim-Williams, Riley, Herrera, Campbell, Hastie & Fillingim (2007) studies African-American, Hispanic Americans and non-Hispanic White Americans.

• Study participants were assessed using three experimental pain measures: thermal, cold pressor and ischemic.

• Ethnic identify was assessed using the Multi-group Ethnic Identity Measure ( MEIM)/

• Ethnic group differences in pain responses were observed.

Cultural Differences in Pain Sensitivity

•African-American and Hispanic subjects exhibited lower cold and heat pain tolerances than non-Hispanic White Americans.

•Pain range (tolerance threshold) was computed for heat, cold and ischemic pain and the two minority groups again had lower values compared to non-Hispanic White Americans.

Cultural Differences

•Theses finding were consistent with earlier studies that found that ethnic identity was associated with pain sensitivity and that African Americans have a lower pain sensitivity than non-Hispanic Whites (Greenwalk, 1991, Edwards and Fillingim, 1999, Edwards, et al, 2005, McCarcken, et al, 2001, Riley, et al, 2002 and Green, et al, 2003).

Culture and Treatment Decisions•Other studies have focused on pain

treatment decisions.

•African Americans are less likely to be prescribed opiods fro chronic pain complaints (Anderson, Green & Payne, 2009; McCarberg, 2008; Baker & Green, 2005).

Cultural Group

Response to Pain

Health and illness Beliefs

ProviderInformation

African American

Stoicism or may vocalize pain

Being in harmony with nature. Illness is punishment.

Include family in plan of care.

Strong fear of addiction.

Hispanic/Latino May exhibit stoicism or vocalize pain.

Health is reward from God.

Machismo Let males know they are still strong and have courage

Cultural Group

Response to Pain

Health and Illness Beliefs

Provider Information

Hispanic Illness are imbalances of hot-cold or wet dry; the evil eye (malojo), being frightened (susto), or having an intestinal blockage (empacho).

May utilize fold medicine before seeking Western medicine.

Suffering is viewed as a Penance.

Family is important.

Cultural Group

Response to Pain

Health and illness Beliefs

Provider information

Asian May exhibit stoicism, emotional restraint of anger and pain

The idea of harmony and balance can be found in the following: Shinto, Confucianism, and Buddhism

Health is balance between self and universe.

Illness lack of sleep, poor diet, and loss of family, spiritual or environment harmony; spiritual world.

Suffering in silence is viewed as virtuous.

Establish a comfortable environment that allows sharing of pain complaints.

Use of alternative rx.

Prevalence of Culturally Discordant Care• Although 12.2% of the United States population is

African American, only 2.2% of physicians are Africa American (U.S Department of the Census, 2009).

• This lack of diversity in providers has resulted in frequent cross-cultural encounter.

• Providing culturally competent care has come to be viewed as a cost-effective strategy in providing sensitive, effective care during cross-cultural encounters (Giger & Davidhizar, 2007).

Culturally Competent Patient Education• Defined as the integration and application of low-back pain

information as well as socio-cultural knowledge combined with an understanding of the values and needs of the African American patient (Dahan, et al, 2007).

• Culturally competent education was operationalized as the culturally competent educational intervention (CCEI).

• Educated participants that chronic pain may be impacted by cultural factors or differences specific to Africa American patient.

Study Summary• The three experimental hypothesis were that group of

subjects revieving a cultually competent health education program would:

• Demostrate decrease pain as measured by visual analogue scale scores.

• Improve in functional status as measure by the Roland Morris questionnaire.

• Increase in quality of life indicators as measured by the WHOQOL-100 Astralian version, compared to the controls.

Conclusion• African American (Black Non-Hispanic)

experience significant health disparities compared to the Caucasian (White Non-Hispanic) population.

• African Americans are often involved in cross-cultural encounter when seeking health care.

• The receipt of cross-cultural healthcare can negatively impact patient health outcomes.

Conclusion

•Research findings suggest that culturally competent healthcare can diminish the negative effects of cross-cultural health care encounters.

•Health disparities in the diagnosis and management of many disease states such as chronic low-back pain is pervasive, unjust, and totally avoidable (Borkhoff et al. , 2011).