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Carolyn Buesgens, MA, RN-BC, ANP-BC Minneapolis VAHCS 1 Objectives 1. Define factors contributing to increased complexity and risk in patients with chronic pain 2. Explain the limitation of opioids as unimodal therapy for chronic pain 3. Describe a multimodal rehabilitation approach in addressing factors of high risk or complex chronic pain 2 3 Biological components Psychological components Social components 4 • • • • • • • • • • • • 41year-old man with chronic low back pain s/p lumbar epidural spinal injections and lumbar fusion 2011 EMG: No evidence of peripheral neuropathy of the LE Past history of Valium overdose and suicide attempts. Positive family hx substance abuse Mental health diagnoses: depression, anxiety disorder, opioid and alcohol dependence, mood disorder r/t medical condition. Poor activity tolerance on Methadone 90 mg daily (limited standing and sitting) Left his job two years ago Adjuvant medications: gabapentin, cyclobenzaprine, venlafaxine. Patient expressed desire to come off Methadone Non-pharmaceutical approaches: stress management classes, pain coping skills class, depression management skills, ACT classes. Physical therapy “didn’t work” 5 substance abuse addiction medical comorbidities number of pain complaints past functional history psychiatric issues concomitant rx for sedative-hypnotics and/or high dose opioid 6 Recent estimates suggest that pain and depressive disorder co-occur 30-60% of the time Anxiety disorders may be present 35% of the time among person with chronic pain Pain and PTSD co-occur; 20-34% of persons with chronic pain meet criteria for PTSD; chronic pain is present in 45-87% of persons with PTSD Pain is present in 37-61% of patients seeking substance use disorders treatment. Pain undermines effective treatment for depression, anxiety disorders, PTSD, and substance use disorders. 7 When disability greatly exceeds what would be expected on the basis of physical findings alone, When patients make excessive demands on the health care system When patients persist in seeking medical tests and treatments that are not indicated When patients display significant emotional distress (e.g. depression or anxiety) When patients display evidence of addictive behaviors or continual non-adherence to the prescribed treatment regimen. Adapted from Turk et al, 2010 8 Complex-chronic pain does not respond to our usual treatments (the “pain patients”) Syndrome encompasses a wide variety of painful conditions Pattern of declining function (in spite of progressively more aggressive, expensive, and risky medical treatments Unpleasant interactions. Dissatisfied customers. Medication adherence issues Overwhelmed and overwhelming Iatrogenesis is a significant problem for this population! A. Mariano Seattle VA 9 Kirsh,KL, Passik, S; Exp Clin Psychopharm, 2008; 16(5) 10 Not all patients are good candidates for opioid therapy Risk stratification is helpful in directing a course of treatment Low-risk Intermediate-risk High-risk 11 Opioid Risk Tool (ORT) Screener and Opioid Assessment for Patients with Pain (SOAPP) Drug Abuse Screening Test (DAST) CAGE-AID STARS/SISAP Current Opioid Misuse Measure (COMM) 12 Opioids are such a big part of the problem, principally, because they are such a small part of the solution.” Anthony Mariano, PhD Seattle VAMC 13 High dose opioid use occurred in 2.4% of all chronic pain patients and in 8.2% of all chronic pain patients prescribed opioids long-term. The average dose in high-dose group was 324.9 (SD=285.1) The only significant demographic difference among groups was race w/ black veterans less likely to receive high doses. High-dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy low back pain, and nicotine dependence diagnoses were associated w/ increased likelihood of high-dose prescriptions. High dose patients frequently did not receive care consistent w/ treatment guidelines; There was frequent use of short-acting opioids, urine drug screens were administered to only 25.7% of patients in the prior year, and 32.% received concurrent benzodiazepine rx, which may increase risk for OD and death Morasco et al, 2010 14 Veterans with mental health diagnoses prescribed opioids, especially those with PTSD< were more likely to have comorbid drug and alcohol use disorders; receive higher-dose opioid regimens; continue taking opioids longer; receive concurrent prescriptions for opioids, sedative hypnotics, or both; and obtain early opioid refills. Seal et al, 2012 15 2012: A memorandum authored by the chief of staff launched the Opioid Safety Initiative limiting total daily opioid dose to < 200 MED 16 Bohnert et al. Association between opioid prescribing patterns and opioid overdoserelated deaths. 2011. JAMA; 305: 1315-1321. Dunn et al. Opioid prescriptions for chronic pain and overdose. 2010. Annals of Internal Medicine; 152: 85-92. Gomes et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. 2010. Arch Int Med; 171;686-693 17 2012 o Primary Care Team training and education o Pharmacists and clinical psychologists closely aligned with each clinic o A chronic pain consult service was begun o Patient Pain Education Class started o Medicine Grand Rounds highlighting available behavioral pain programs o Tracking/performance measures 18 Percent Reduction in Number of Patients at 50+, 100+, 200+, 500+ and 1000+ MEQ/day Minneapolis VA May 2011 - September 2012 10% 0% -10% -20% -30% -40% -50% -60% >50 MEQ -8% >100 MEQ -19% -27% >200 MEQ >500 MEQ -44% -50% >1000 MEQ Your patient does not have a right to opioids. They have a right to good care and appropriate treatment and in some cases, withdrawing or withholding opioids is ethically mandated. A Mariano, PhD Seattle VAMC 20 21 Assessment Identification of needs (and risk factors) Chronic Pain Care Plan Appropriate referrals Ongoing Education Individualized follow-up/monitoring 22 23 Validation – much of the struggle with patients relates to our communication of doubt Education – the basis of effective long term care is a shared understanding of chronic pain Motivation – patients vary in their willingness to engage in self management Activation – primary clinical focus is on changing the way patients relate to pain Mariano, PhD Seattle VA 24 Shared by patients who are overwhelmed by pain and providers who find these people overwhelming: Belief that objective evidence of disease/injury is required for pain to be “real” View of pain as the only problem, and which needs to be avoided at all costs Expectation that urgent pain relief is the major goal of treatment Overconfidence in medical solutions Provider is the “expert” responsible for outcomes Patient is helpless “victim” of underlying disease/injury A. Mariano Seattle VA 25 Optimal treatment paradigm Comprehensive assessment and individualized treatment plan Offer hope and help patient connect with their valued life End uncertainty 26 “Treating a pain patient can be like fixing a car with four flat tires. You cannot just inflate one tire and expect a good result. You must work on all four.” Penny Cowan, Executive Director American Chronic Pain Association 27 Supportive therapies Cognitive-behavioral therapy Re-conceptualizing of pain as problem to be solved Coping skills training Behavioral Interventions Altering pain-related communication Behavioral activation Self-regulatory treatments Biofeedback Relaxation training (progressive muscle relaxation; autogenic training) Hypnosis 28 Mindfulness based programs ACT: Acceptance and Commitment Therapy Books: - Dahl, J.A. & Lundgren, T. (2006). Living beyond your pain: Using acceptance and commitment therapy to ease chronic pain. Oakland, CA: New Harbinger. -Dahl, J.A., Wilson, K.G., Luciano, C., and Hayes, S.C. (2005). Acceptance and commitment therapy for chronic pain. Reno, NV: Context. Mind-Body Skills -cmbm.org Mindfulness Based Stress Reduction Kabat-Sinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 29 Urgent and absolute pain relief, while it is an appropriate goal in acute and cancer pain, is an inappropriate goal in the treatment of chronic pain. It should not be the major focus of treatment. A. Mariano, PhD Seattle VAMC 30 Redefine the problem and the solutions Expect some pain – but reject disability and suffering Have a plan for bad days Activate, Activate, Activate Build a health and hopeful lifestyle 31 Missed opportunities to improve health and prevent further morbidity and disability Address co-morbidities Sleep apnea Insomnia Obesity DM Smoking 32 “…the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment, and the continued use of ineffective treatments.” The Model Policy for the Use of Controlled Substances for the Treatment of Pain Federation of State Medical Boards of the United States, Inc. Medical Boards, 2004 33 Arnstein, P., St Marie, B.. Managing Chronic Pain with Opioids: A call for change. . Nurse Practitioner healthcare foundation. 2010. www.nphealthcarefoundation.org 2010 accessed 10/01/12. Breckenridge J, Clark JD. 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