Download Treatment of Complex and High Risk Chronic Pain: A Rehabilitation

Carolyn Buesgens, MA, RN-BC, ANP-BC
Minneapolis VAHCS
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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
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Biological components
Psychological components
Social components
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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”
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substance abuse
addiction
medical comorbidities
number of pain complaints
past functional history
psychiatric issues
concomitant rx for sedative-hypnotics and/or
high dose opioid
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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.
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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
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Complex-chronic pain does not respond to our usual
treatments (the “pain patients”)
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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
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Kirsh,KL, Passik, S; Exp
Clin Psychopharm, 2008;
16(5)
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Not all patients are good candidates for opioid
therapy
Risk stratification is helpful in directing a
course of treatment
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Low-risk
Intermediate-risk
High-risk
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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)
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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
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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
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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
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2012: A memorandum authored by the chief of
staff launched the Opioid Safety Initiative limiting
total daily opioid dose to < 200 MED
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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
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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
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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
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Assessment
Identification of needs (and risk factors)
Chronic Pain Care Plan
Appropriate referrals
Ongoing Education
Individualized follow-up/monitoring
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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
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Shared by patients who are overwhelmed by pain
and providers who find these people
overwhelming:
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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
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Optimal treatment paradigm
Comprehensive assessment and individualized
treatment plan
Offer hope and help patient connect with their
valued life
End uncertainty
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“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
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Supportive therapies
Cognitive-behavioral therapy
Re-conceptualizing of pain as problem to be solved
 Coping skills training
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Behavioral Interventions
Altering pain-related communication
 Behavioral activation
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Self-regulatory treatments
Biofeedback
 Relaxation training (progressive muscle relaxation;
autogenic training)
 Hypnosis
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Mindfulness based programs
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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.
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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.
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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
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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
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Missed opportunities to improve health and
prevent further morbidity and disability
Address co-morbidities
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Sleep apnea
Insomnia
Obesity
DM
Smoking
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“…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
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