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10/24/2013
Medical and Psychological
Management of the chronic
back pain patient
Marc Cooper, PH.D.
Director of Psychological and Behavioral Health Services
Pain Medicine Associates
Johnson City, Tennessee
Disclosure Statement of
Unapproved/Investigative Use
I, C. Marcus Cooper, Ph.D.
Do Not anticipate discussing the unapproved/
investigative use of a commercial product/device
during this activity or presentation
Purpose of
Presentation
1. Help you as physicians decide whether you want to be
in the pain management business, to what extent, and
how to do it safely.
2. Help you understand the appropriate role of
psychology in helping you with chronic pain patients.
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History of Pain Management:
Follow the Money (reimbursement)
• 1980’s to 1990’s: “The Tollison Approach”
Physical Therapy (work hardening) and
psychological support.
• 1990’s to 2010’s: Injection Therapies, implant
devices, and Medical Management.
• 2010 and Beyond: 3rd Party Management and
government oversight: Functional Improvement
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Role Of Psychology in
Chronic Pain Management
• 1. Help the physician assess the risk of
misuse, abuse, or diversion of medication.
• 2. Establish behavioral health strategies and
treatment approaches to involve the patient in
their recovery process.
1. Evaluation of Risk: Special
Consideration prior to initiating opioid
therapy:
• Patient living in a Rural Area or have low income
• Medicaid population (Tenncare?)
• Patients who have already seen multiple providers for a pain
problem in the past: doctor shopping
• Patients already on an abusable substance: benzodiazipine
• Patients with history of mental health problems
• Patient with history substance abuse problems
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Dr. Cooper’s Continuum of Risk: What
places a patient in a high risk category
from a psychological point of view
• Presence of past or present psychiatric disorders including major
depression, bi-polar disorders, anxiety disorders, alcohol or drug history,
and personality disorders. (The development of psychological problems
prior to the pain problem increases risk as does poor treatment response
to past psychiatric, drug or alcohol problems).
• Poorly controlled sleep disorder.
• Obesity and sedentary life style especially before injury.
• Nicotine Dependence
• Financial issues: Unemployment and no visible sign of income, social
security disability, litigation, workman's compensation issues.
• Social Risk factors: Spouse's,children's, family member's, grand children's
mental health and drug use history.
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Dr. Cooper’s Continuum of Risk:
What places a patient in a low risk
category
• The absence of the above personal risk factors in the
patient.
• No overt drug/ETOH problems in the patient's
immediate social environment.
• Also positive factors include the fact that the patient
has a stable and positive social network. Pain has not
kept them from their social functioning, work, or
activities. They may have modified them but they still
are a functional person in the world.
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2. Behavioral Health treatment
in chronic pain patients
• Therapeutic strategies for the mental health/ drug
concerns: 85% of chronic pain patients in our
practice had a mental health disorder: e.g..
depression/anxiety.
• Therapeutic strategies sleep.
• Therapeutic strategies for nicotine dependence.
• Therapeutic strategies for obesity and
deconditioning.
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Goal of Psychological and Medical Pain
Management Treatment: Improve
cognitive, social, occupational, and ADL
functioning.
• “Patients who are passive in response to (threat)
pain show greater distress and disability than
patients who attempt to solve their problems.”
• “Patients who feel they can control their pain to
some degree have less fear and disability.”
• Snowturek Al, Norris MP, Tan G. Active and passive coping strategies in
chronic pain patients. Pain 1996; 64: 455-62
1. Psychological/Behavioral Health
Treatment Options or
Recommendations
• Individual psychotherapy, cognitive behavioral therapy, emotional
freedom techniques.
• Marital and Family Therapy.
• Suggestions regarding psychotropic medications or referral to
psychiatrist.
• Biofeedback, relaxation therapy, stress management, guided
imagery, self-hypnosis training, meditation.
• Drug or ETOH outpatient/inpatient treatment.
• AA or NA.
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2. Psychological/Behavioral Health
Treatment recommendations
• Behavioral Strategies for Sleep
• Consideration for Physical Therapy: (Tens Unit, traction, ultrasound and estim, desensitization, therapeutic exercise, ice massage)
• Consideration of Home exercise program, silver sneakers or senior citizens
group, yoga classes
• Weight loss programs
• Stop smoking program
• Diabetic cooking class or referral to dietitian/nutritionist
• Fibromyalgia Program/ anti-inflammatory diet
• Massage therapy, acupuncture, chiropractic, Theracane acupressure
technique, Edward Casey’s Violet Ray Technique.
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What Do You Do First As a
Physician Helping Chronic Pain:
Guidelines for chronic Benign Pain
• Proper Diagnosis with history, physical exam,
and appropriate diagnostic testing documented in
chart.
• Rule out the need for surgical intervention.
• Attempt conservative treatments prior to initiating
opioid therapy: physical therapy,NSAIDS,
massage therapy, injection therapies,
acupuncture.
Professional Reminders
• “The Extent of complaint and disability
reported by the pain patient can not be
explained by the extent of damage or
disease.”
• “Pain (expression) is not a reliable indicator of
tissue damage and tissue damage is not a
reliable indicator of pain.”
• Improved function is our primary goal, not
absence of pain.
•
British Journal of Anaesthesia: Vol. 87. Issue 1. pp. 144-152. 2001.
Second: Professional Considerations
prior to initiating long-term opioid
medication management
• Do you want to do this type of work?
• What additional structures do you need to put in
place to treat chronic back pain patient with
opioids?
• At what level of opioid prescribing are you
comfortable with?
• When do you refer to a pain specialist?
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What tools, policies, and
procedures will you need to set up
to prescribe opioids
• Obtain validated risk assessment tool or formal psychological
evaluation prior to considering opioid treatments
• Have written opioid agreement to be reviewed by provider and
signed by patient.
• Have written informed consent documenting risk for the patient.
• Set up a monitoring compliance program: reviewing control
substance monitoring database (CSMD), Urine Drug Screens
(UDS) and pill counts and documentation of improved function
in the chart.
Risk Assessment
Tools
• Pain Medication Questionnaire
• The Screener and Opioid Assessment for
Patients with Pain (SOAPP)
• SOAPP (SOAPP-R)
• Opioid Risk Tool (ORT)
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Multidisciplinary Treatment
Recommendations
• Treatment recommendations are based on risk
profile and other psychological, behavioral, and
social variables revealed in testing and clinical
interview.
• The decision to write for opioids are for the
physicians to make, the pain psychologist role is
to assist the physician in making that decision
and how it should be done.
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High Risk Treatment
Recommendations
•
Typically long acting medications only with no short acting medications or “break
threw” medications.
•
Medications should be written for one month only (no exceptions) with face to face
clinic visit. No refills on hydrocodone (lortab) or tramadol (ultram) even though it is
acceptable by guidelines.
•
Patients should be required to bring in all medications (even from other doctors) at
each visit or pill count.
•
Check Tennessee Data Base at each visit. Current law is required twice per year.
•
3 to 4 urine screens each year and occasional calls for pill counts.
•
Required adjunctive treatment with signed releases of information in chart so that all
providers can communicate with each other in regards to patient’s compliance.
(psychiatry, physical therapy, psychotherapy, etc)
•
Consideration can be given to making opioid treatment contingent upon behavior
health changes. Monitor compliance and document improvement in function or
discontinue opioid treatment.
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Low Risk Treatment Options
•
Long acting medications preferable, but short acting medications can be used.
•
Pill counts only for pain clinics medications.
•
Medications may be prescribed on a 3-month basis (depending on medication) after
prescribing physician is comfortable with patient.
•
Check Tennessee Data base as required by state statutes for opioids and
benzodiazepines. Current law is once per year or when a change in medications
occurs. (General providers).
•
Urine screens only as required by state law (2 per year). No need for additional
ones.
•
Behavioral health changes or assistance is optional. No need for treatment team
approach.
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Possible Future
OpioidTreatment Prescribing
Guidelines
•
Documentation of objective need for opioids and failed improvement from other modalities.
•
Validated risk assessment tool in chart
•
Signed agreement form
•
No suboxone prescribed for pain management. Methadone limited to 30 mg/ per day.
•
No more than 1 type of short acting medication; no more combinations of 2 (like lortab and/or ultram)
•
No more than 4 short acting medications per day. Use long acting medications if the patient is requiring
higher levels and discontinue short acting. No “break threw” medications unless there is clear objective
reasons.
•
No concomitant pain medication written with a benzodiazepine without consultation with mental health
provider and documented in chart. Psychological assessment required before adding a benzodiazepine.
•
Prescription written only for 30 days with face to face visit. (Type 3 drugs like hydrocodone, tramadol,
gabapentin, (possibly pregablin) are current exceptions but should only be written with 2 refills).
•
Convert medications to morphine equivalent and consider referral to pain specialist above 100 mg. per
day. Required referral to pain specialist above 200 mg equivalent. Psychological assessment may be
considered and required prior to initiating any long term narcotic and especially when considering
dosing above 100 mg. per day.
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Consequences for Not Following
opioid Prescribing guidelines
• Fines
• Revocation of license
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Advantages for the New
Guidelines
• The new guidelines provide an easier way to
deal with your patients.
• The new guidelines provide you some
protection from professional and legal
problems.
• The new guidelines are easy to follow and set
up in your office.
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