Download Pain Management

Chronic Pain Management
What is it?
What can be done?
What is Functional Restoration?
IS Return to Work possible?
Steven Feinberg, M.D.
John Massey, M.D.
Bay Area Pain & Wellness Center
Functional Restoration Program
Los Gatos, California
Introduction
The Pain Puzzle
Pain is a complex clinical phenomenon
Pain is a symptom when it occurs acutely
but a disease when it presents chronically
Exam time consuming and physically and
psychologically taxing to physician and
patient
Cost of Chronic Pain
Billions yearly in health care costs and
lost work productivity
Considerable human suffering
– Individual
– Significant others
Society loses
– Loss of a productive member of society
What is Chronic Pain?
Chronic pain is persistent or recurrent
pain, lasting beyond the usual course of
acute illness or injury, or more than 3 - 6
months, and adversely affecting the
patient’s well-being
Pain that continues when it should not
What is Acute Pain?
Physiologic response to tissue damage
Warning signals damage/danger
Helps locate problem source
Has biologic value as a symptom
Responds to traditional medical model
Life temporarily disrupted (self limiting)
What is Chronic Pain?
Difficult to diagnose & perplexing to treat
Subjective personal experience
Cannot be measured except by behavior
May originate from a physical source but
slowly it “out-shouts” and becomes the
disease
It has no biologic value as a symptom
Life permanently disrupted (relentless)
Pain Classification
Classification by Mechanism
– Nociceptive: a normal physiologic response to
potential or actual tissue damage
– Neuropathic: a pathophysiologic pain state
associated with inflammation or peripheral
nerve injury
– Central: a pathophysiologic pain state
produced by lesions of the central nervous
system that occur in the spinal cord,
brainstem or brain
The Scope & Treatment of Pain
Chronic pain is never unidimensional
It is never purely biological or solely
psychological
The treatment of pain is still in the "gray"
area of medical practice
It is approached differently depending on
the education, training, experience and
bias of the physician
Getting to Chronic Pain
Why and how do some people become
dysfunctional chronic pain patients?
How does a person with a problem become
a patient with an illness? Nortin Hadler, M.D
The responsibility for this disastrous
situation rests with the healthcare system,
the medical community and the patient and
their significant others
Chronic Pain is Devastating
Robs the individual of his or her ability to
have a productive, meaningful and
enjoyable life
It takes away hobbies, recreation, friends,
and the ability for the person to provide
financial support to his or her family
through gainful employment
The individual is not comfortable while
awake, and usually sleeps poorly at night
Chronic Pain Characteristics
Weight gain and sexual difficulties occur
Anger, depression, despair and irritability
are common
Chronic pain is often accompanied by loss
of hope and self-esteem
It saps the individual’s energy and the
ability to think straight
Chronic Pain Characteristics
Pain behavior (braces, canes, posturing, etc.)
Significant lifestyle alterations and losses
Drug overuse, misuse & dependency
Multiple medical and surgical failures
Not improving with traditional care
Treatment is often fraught with side-effects
– Cognitive, Behavioral, & Medical
Chronic Pain Characteristics
Inactivity & excessive down time
Somatic preoccupation
Continued medical cure seeking
Subjectives outweigh objectives
Physical deconditioning & low energy
Perceived disability & inability to work
Chronic Pain Medical Care
Providing quality chronic pain medical care
is often more "art" than "science“
The H&P is of critical importance
It is important to get a sense of the depth
and breadth of the person’s life
experiences and current social situation
What are the individual’s beliefs about the
cause, meaning, impact, expectation,
perceptions and goals regarding the pain
Chronic Pain Medical Care
Recognize problem cases or "Red Flags“
Determine motivating factors and what the
patient needs and wants?
Recognize the difference between organic
and non-organic disability factors
It is important to recognize the rare
malingerer who is perpetrating a fraud
from the legitimate patient who magnifies
or exaggerates symptoms unconsciously
to gain attention and support
Chronic Pain Treatment
Difficult for health care professionals
Chronic pain management not taught
Conventional medical education does not
teach us how to deal with chronic pain
The education MDs receive actually teaches
how to mismanage chronic pain problem
Patients are demanding & difficult
Payers suspicious of chronic pain treatment
Utilization Review is problematic
CP Internal Risk Factors I
The individual's past pain experiences
Cultural issues
Subjective pain intensity
– individuals who experience high levels of
subjective pain intensity during the acute
phase appear to have a significantly increased
risk for developing chronic disabling pain
Secondary gain/rewards for illness
behavior
CP Internal Risk Factors II
Premorbid psychological make-up:
– Depression
– MMPI Findings
– Axis II Personality Disorders
History of dysfunctional childhood
– Emotional
– Physical
– Sexual abuse
– Dysfunctional or distant parents
CP Internal Risk Factors III
Substance abuse (alcohol, tobacco, drugs)
Marital and/or family problems
Job dissatisfaction
Unemployment
– The degree of risk for developing chronic pain is
influenced by the existing job market, the climate
for rehiring and the patient's transferable skills
CP Internal Risk Factors IV
The low activity/high pain behavior factor
– sedentary lifestyles and/or exhibit significant overt
pain behaviors and demonstrating extreme reactions
during physical examination
Negative beliefs/fear about pain manifests when
patients express strong beliefs or fears that their
pain is harmful, disabling, or out of their control,
or that increasing their activity level would
increase their pain
Chronic Pain External Factors
Physicians & significant others often support
pain complaints and behavior
Continued tests and medications for
increasing complaints support the person’s
perception of being dysfunctional
Illness behavior rewarded by attention from
others and time out from unpleasant tasks
Incentives & rewards (financial, time off, etc)
for illness behavior
Treatment Goals - I
Reduce and manage pain
– Decreased subjective pain reports
– Decreased objective evidence of disease
Optimize medication use
Increase function & productivity
Restore life activities
Increase psychological wellness
Reduce level of disability
Treatment Goals - II
Stop cure seeking
Reduce unnecessary health care
Prevent iatrogenic complications
Improve self-sufficiency
Achieve medical stabilization
Prevent relapse / recidivism
Minimize costs - maintain quality
Return to gainful employment
Effective CPP Evaluation & Rx
It is more important to know about the
patient who has the disease than about the
disease the patient has Sir William Osler
Readiness to Change concept
– Ready to change
– Yes But…
– No way…
There is a fine line for the treating physician
between reasonable caring and concern vs.
enabling illness and adding to the patient’s
sense of entitlement and disability
Effective CPP Evaluation & Rx
Just as it is important to know how to
treat, it is also important to know when to
stop - some patients can’t be “fixed”
Limit exposure to invasive interventions
Start by doing simple things first
– Listening, understanding and educating
– When reasonable, progress to appropriate
& increasingly invasive treatments,
medications & procedures
Chronic Pain Evaluations
comprehensive multidisciplinary
evaluations offers a means of developing
an appropriate treatment plan
This can help identify factors which may
prolong complaints of pain and disability
despite traditional medical care
Such an evaluation can also identify who
would benefit from a more structured and
intensive functional restoration program
Treatment Approaches
Medications
– Non-opioid analgesics (acetaminophen &
NSAIDs)
– Opioids
– Antidepressants
– Neuroleptics / Psychotropics
– Anticonvulsants
– Membrane stabilizers
– Muscle Relaxants
– Systemic Local Anesthetics
– NMDA-receptor Antagonists
Medication Management
Medication use should be individualized
and determined by
– benefit
– cost
– potential side effects
– other medical problems
Partial rather than full relief of pain, sleep
loss, or other symptoms is often a more
realistic goal with using medications
Analgesics for Chronic Pain - I
Analgesic and other drugs are the most
common method of chronic pain treatment
Pain medications can be a blessing for
some patients in chronic pain, but they are
not universally effective
Analgesics are generally effective for tissue
injury (nociceptive pain) but less effective for
pain resulting from damage to nervous
system (neuropathic pain)
Analgesics for Chronic Pain
Short-term use of analgesics is rarely
worrisome, but prolonged use increases
the possibility of adverse reactions
including daytime sleepiness, internal
organ problems, poor coordination and
balance (possibly leading to falls),
cognitive dysfunction with memory and
concentration difficulties, behavioral
changes and addiction
Opioids
A select group of pain patients benefits
from opioids, with resultant pain reduction
and improved physical and psychological
functioning
They have minimal side effects & show
increased activity levels & less pain
Other patients do poorly with opioids,
experiencing tolerance and side effects,
especially with escalating doses
Measuring Opioid Usefulness
Each individual with chronic pain should
be viewed as unique and the ultimate
outcome of the use of opioid medication
must be viewed in terms of
– Pain relief
– Objective gains (function or increased activity)
– Does taking an opioid allow the person to be
happier and do more things without
unacceptable side effects or do the
medications only create more problems and
no observable change in activity level?
Adjunctive Treatment Modalities
Joint, bursal & trigger point injections
Botulinum toxin injections
Nerve root and sympathetic blocks
Peripheral and plexus blocks
Facet and medial branch injections
Lidocaine infusions
Epidurals
Neuroablative techniques
– Chemical, Thermal, & Surgical
Neuromodulation
– Spinal cord stimulators & Implanted spinal pumps
Physical & Occupational Therapy
Active
– Improved body mechanics
– Spine stabilization
– Stretching & strengthening
– Aerobic conditioning
– Aquatics therapy
– Work hardening
– Self-directed fitness program
Psychological Approaches
Non-drug pain management skills
– Anxiety & depression reduction
– Biofeedback, relaxation training, stress reduction
skills, mindfulness meditation, & hypnosis
– Cognitive restructuring
Improve coping skills
Learn activity pacing
Habit reversal
Maintenance and relapse prevention
Functional Restoration
Locus of control issues
Timely and accurate diagnosis
Assessment of psychosocial strengths and
weaknesses including analysis of support system
Evaluation of physical and functional capacity
Treatment planning and functional goal setting for
return to life and work activities
Active physical rehabilitation
Cognitive behavioral treatment
Patient and family education
Frequent assessment of compliance and progress