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Pain Management
Presentation 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
Contextual Examples
• 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.
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.
Epiphenomena
1.Substance use disorders or varying severity with their attendant central
nervous system side effects
2.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 others
7.Unpleasant and lasting mood and affect changes
8.Decrease in feelings of self-esteem, self-worth, and self-confidence
9.Escalating psychosocial withdrawal and increased loss of gratification from
these interactional inputs
10.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 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 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
 CBT
Cognitive restructuring (from catastrophic and
maladaptive to helpful
and realistic thoughts)
o Biofeedback
o
Guided imagery, relaxation, meditation
o
Assertiveness training
o
Expressive writing
o
Mindfulness
o
Psychoeducation
o
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 care
o Proper utilization of the healthcare system
•
“Good Candidates” to Consider:
Chronic pain
Willingness to reduce reliance on medication
Failed some other modalities
Concomitant depression or anxiety or coping
skill issues
Able to make time commitment (only 20 halfdays)
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 Continued
return to work rates (rtw)
A compilation of 18 studies:
▫ Conventional medical treatment
o RTW rates = 0 – 42%, Average = 27%
▫ CPP’s
o RTW 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 Preventative
 Gatchel et al. (2003) Randomized, controlled study:
 Acute low back pain patients “high risk”
 Randomly assigned: Early FRP or TAU
 Results: 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
Provider
Patients get better
Patients are taught a new skill-set for dealing with
pain
Patients learn new communication skills
Depression and anxiety are reduced
Patients 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 name
do 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 short
time?
• 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 your
pain?
• What are the chief problems that your pain
cause for you?
• What kind of treatment do you think you
should receive? What are the most
important results you hope to receive from
the 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 help
you 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 to
about your pain? What do they know? What do
you want them to know?
• Do you have family and friends that help you
because 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 and
religious 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 nonminorities.
• 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 AfricanAmerican, 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
Provider
Information
African American
Stoicism or may
vocalize pain
Being in harmony
with nature.
Illness is
punishment.
Include family in
plan of care.
Health is reward
from God.
Machismo Let
males know they
are still strong
and have courage
Hispanic/Latino
May exhibit
stoicism or
vocalize pain.
Strong fear of
addiction.
Cultural Group
Hispanic
Response to
Pain
Health and
Illness Beliefs
Provider
Information
Illness are
imbalances of hotcold 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
Health is balance
between self and
universe.
Suffering in
silence is viewed
as virtuous.
Illness lack of
sleep, poor diet,
and loss of family,
spiritual or
environment
harmony;
spiritual world.
Establish a
comfortable
environment that
allows sharing of
pain complaints.
The idea of
harmony and
balance can be
found in the
following: Shinto,
Confucianism,
and Buddhism
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 WHOQOL100 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).