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Doc, I’ve Got This Pain
Steven M. Moskowitz, MD
Senior Medical Director, Paradigm
Key Take-Home Lessons on Chronic Pain
By the end of this presentation, you should understand the importance of
systematic management by physicians
 Objective assessment and criteria
 Careful Selection
 Avoid trial and error
 Measure effectiveness
 Withdraw treatments that are not effective
 Perspective and context
2
Chronic Pain Remains a Chronic Problem
Despite innovation, chronic pain persists as one of the most chronic problems in the
US.
 $100 billion estimated annual cost in the US of health care, lost income
and lost productivity due to chronic pain according to the NIH1
 76 million Americans suffer from chronic pain according to the NIH1
 26% of Americans age 20 years and older—an estimated 76.5 million
Americans—suffer from “chronic pain”
 80% of physician office visits due to pain4
 Pain medications are the 2nd most commonly prescribed drugs in the US5
 Generic Vicodin is top medication prescribed
Sources: 1. NIH Guide: New directions in Pain Research (National Institutes of Health, September 4, 1988); 2. Flash Report (Workers Compensation Research Institute, August 2007); 3.
Pain and Absenteeism in the Workplace (Ortho McNeil Pharmaceuticals 1997); 4.Koch, H. “The management of chronic pain in office-based ambulatory care: National Ambulatory
Medical Care Survey (Advance Data from Vital and Health Statistics, No. 123, DHHS Publication No. PHS 86-1250); 5.Schappert, S.M. “Ambulatory care visits to physicians offices, hospital
outpatient departments and emergency departments”: United States, 1996. 6. (Turk, D.C., Okifuji, A., Kalauokalani, D. Clinical outcome and economic evaluation of multi-disciplinary pain
centers. A.R. Block, E.F. Kremer, and E. Fernandez)
3
Chronic Pain and Drug Use
Chronic pain is a persistent problem in workers compensation, and with it are
significant drug-related issues.
■ 14% of claims and 11% of payments are due to chronic pain1
■ 50 million work days are lost in the US due to chronic pain2
■ Treatment statistics tend to be worse for worker’s compensation patients
■ 20% of workers’ compensation medical costs of fully developed claims are spent on
prescription drugs; narcotics account for 34% of this spend
■ Admission rates for abuse of opiates other than heroin—including prescription
painkillers—rose by 345% from 1998-2008
■ 120,000 Americans a year go to the ER after overdosing on opioid painkillers3
1. According to the Workers’ Compensation Research Institute (WCRI) within the 14 states they rate.
2. According to a study conducted by Ortho-McNeil Pharmaceutical.
3. According to Laxmaiah Manchikanti, CEO for the American Society of Interventional Pain Physicians.
4
Back Pain
A Common Symptom
Back Pain, All Pain, Is Often A Lifestyle Condition
■ 70-80% lifetime incidence. Up to 10% incidence per year
■ The CDC 2010 reported that 30% of people had LBP in the prior 3 months1.
• Ages 18-24 (21%), 25-44 (27%), 45-54 (32%), 55-64 (33%), 65-74 (30%), >75 (34%)
• Neck pain: less frequent by about 40-50%
• Joint pain: Age 18-44 (21%), 45-64 (42%)
• Hospice care patients symptoms at last hospice visit before death: Pain 33.3%
■ 250,000 lumbar surgeries are performed annually
• 2006-2007 rates have kept steady since 1996-97 for 45-64 year old group, increased by 67% for
those over 65
• For comparison, knee replacement has increased by over 100% and total hip replacement by just
under 100%
1. CDC Health, United States 2020
5
Back Pain
Back surgery is not a wise “last resort”
■ Having back surgery is a major risk factor for having more back surgery
– 18.9% cumulative risk of additional back surgery in 9 years
• Reoperations after lumbar disc surgery: a population-based study of regional and
interspecialty variations1
– Patients with one reoperation after lumbar discectomy had a 25.1% cumulative risk of
further spinal surgery in a 10-year follow-up
• Risk of multiple reoperations after lumbar discectomy: a population-based study2
■ Most benefits of surgery, for those who benefit from surgery, last 1-2 years compared to those
not having surgery
1.
2.
Spine, 2000 Jun 15;25(12):1500-8.
Spine, 2003 Mar 15;28(6):621-7.
6
Chronic Pain Management Can Seem Chaotic
7
The power of the physician’s pen
8
By writing prescriptions without
investigating, relying on a trial-anderror method without a
comprehensive plan, and using the
newest (most expensive!) treatments
that haven’t been proven, physicians
can contribute to a cycle of chronic
pain and prescription overuse
A Systematic Health Management
Approach To Chronic Pain
10
What is Pain?
11
What is Pain?
12
What is Pain?
The pain experience is both individual and complicated
Pain Perception
Nociception
Somatosensory System
Pain Neurological Interpretation
Neuromodulation
Cognitive Interpretation
Emotional Influence and Response
The Pain Experience
Components of Clinical Pain
Nociceptive Pain
Pain sensation from
damage,
inflammation
Neuropathic
Pain
Pain from nerve
compression, damage
Central
Mechanisms
Secondary
impairments
Complex central
nervous system
interpretation,
regulation, sensitization
Myofascial pain,
stiffness,
deconditioning,
debilitation
Psychosocial
Component
Factors that impact
illness perception,
adaptive coping,
compliance
13
Chronic Pain is Not Acute Pain
Acute pain typically resolves within a certain time frame. Pain lasting beyond this
time is what we refer to as chronic pain. Treatment should differ from acute.
Acute Pain
Chronic Pain
The clinical and claims approaches differ
14
Is All Chronic Pain The Same?
Knowing the terminology can help.
■ Acute pain
■ Acute pain with psychological dysfunction
■ Chronic pain
■ Chronic Pain with psychological dysfunction
■ Chronic pain syndrome
15
Chronic Pain
Chronic pain is a syndrome that emerges at variable speed.
atrophy
depression
atrophy
insomnia
insomnia
PAIN
PAIN
PAIN
weight gain
fear of movement
medical issues
addiction
life roles
Acute Pain
(0-3 months)
Transitional
(3-6 months)
Chronic Pain Syndrome
(Greater than 6 months)
16
Psychological Factors
.
Some
of the more common psychological factors have to do with coping
■ MALADAPTIVE COPING behavior
– Symptom magnification
– Inconsistent performance
– Fear avoidance
– Drug seeking
– Catastrophising, somatization…
■ Pre-morbid personality traits or
psychological problems
■ Concurrent psych issues – Axis I (e.g. depression)
or Axis II (e.g. personality disorders)
■ Somatoform disorders (Axis I or II functional)
■ Stress diathesis model
17
Not All “Pain Management” Philosophy Is The Same
Some styles of pain management can make a patient worse
Biomedical Model
Biopsychosocial Model
■ Definition-search for a pain generator to
extinguish it
■ Definition-pain complaint and experience in
context of beliefs, fears, self limitation,
secondary gains and losses
■ Focus
■ Focus
■ Potential Dangers
■ Potential Dangers
–
Over-reading basic science
–
Trial and error
–
Over-reading of clinical research
–
Loss of “carefully selected” criteria
–
Accumulation of failed treatments
–
Polypharmacy
–
Forgetting the Biological
–
Missing a clinical cue
–
Getting too deep in patient’s lifelong
issues
–
Becoming another dependency
18
Maladaptive Cycle in Entrenched Chronic Pain
If clinicians misinterpret pain behaviors as representing pain generators they
increase treatment, thereby reinforcing maladaptive behavior.
Patient
Maladaptive
Coping
Provider





Lack
of objective
Quick
fixes
measures
Trial and
error approach
Quick fixes
Lack of
objective
Trial
and errormeasures
Poly-pharmacy
approach
Poly-pharmacy
Escalating
interventions
 Illness
Unrealistic
expectations
conviction
 Catastrophizing
Illness conviction
avoidance
 Fear
Catastrophizing
Quick fix seeking
 Fear avoidance
 Quick fix seeking
Maladaptive
Treatment
Patient
Provider
Escalating
interventions
19
The beliefs and actions of patient and provider interact
Sometimes they are not productive
Patient
Maladaptive
Belief
Physician Maladaptive
Response
Impact
Catastrophizing,
fear avoidance,
symptom
magnification
Misdiagnosis/overdiagnosis, escalating
interventions,
polypharmacy
Worse illness conviction due to
failure, iatrogenic disability
Pain is all physical
All biomedical interventions
Overtreat, side effects,
iatrogenic illness, prolonged
disability
(Remember Occam’s Razor)
Poorer results on interventional
Lack of insight:
my pain rating is
15/10
Lack of objective measures
Poor differentiation of helpful
and non-helpful interventions
Desire for quick
Quick fix offer, trial and
Lack of investment in things that
20
Red Flags for Maladaptive Pain Cycle
These may initially be easy to miss.
Injured Worker
Providers
 Symptoms out of proportion to objective
findings-extremely high pain complaint
 Ever-changing diagnosis
 Catastrophizing behavior
 Inordinate disability
 New complaints
 Maladaptive coping/adjustment disorder
 Inconsistent findings or behavior, situational
 Lack of significant benefit from any treatment
 Lack of objective measures
 Adding new body parts
 Trial and error approach
 Escalating polypharmacy, particularly
opioids
 Excessive focus on bio and ignoring
maladaptive coping
 Medication seeking
21
Factors Perpetuating Ineffective Care
How can you work with providers to help turn it around?
Polypharmacy/
Opioids
Treatment
Side
Effects
Activity
Restriction
Ineffective
Care
Implants
Surgery
22
What is a systematic approach
Biopsychosocial Model
A methodical approach to chronic pain
Concepts
Actions
■ Clarify the diagnosis
■
Organized
Measured
Radiculopathy, discogenic pain, facet
arthropathy, SIJ syndrome, failed back
syndrome
■ Coordinate appropriate care
■ Manage behavior, perception, expectations
Evidencebased
Outcome Oriented
23
The Case of the 13 out of 10 pain…
Red Flags: The Case of “11 out of 10” Leg Pain
What is your pain rating?
13 out of 10!
How are the medications working?
The Oxycontin is great, but I need more.
How was that epidural steroid injection?
I felt great for two days!
We’d better get you an MRI and schedule an
ESI and some facet injections.
Doc, can I have a refill of my Oxycontin? I need
a higher dose. And can I get validated parking
for my truck?
25
Biopsychosocial Approach to Procedures
Be systematic
Clarify the Diagnosis
Coordinated and Appropriate Treatment
 Clinical assessment
 Treatment criteria
– Objective criteria for diagnosis
 Criteria for diagnostic testing
– Clear reasons for this test
 Careful interpretation (Danger)
– Common occurrence of incidental
findings
 Behavioral factors
– Catastrophizing, fear avoidance, self
efficacy, secondary gain
– Carefully selected
 Treatment effectiveness measures
– Subjective and objective
 Clear intervention criteria
– Increase or discontinue
 Behavioral interventions
– Set realistic expectations,
accountability, perspective
26
Case 2: New patient, Mr. Spinatus; Accepted shoulder claim
Doc, I can’t lift my shoulder!
■ MD: I read your record and see that you are 43 years old, you are a carpenter and your shoulder has been
hurting for 3 years. Is that correct
■ Patient: Yes it is horrible. When I was in Cabo last week, it hurt the whole time. I could hardly use it.
■ MD: I noticed you have quite a tan. Where is the pain exactly?
The Case of the Disabled
Beachcomber…
■ It starts at my shoulder and goes down my arm to here (he points to his wrist).
■ I see you are on the Fenatyl patch, does it help?
■ Patient: It takes the edge off. The OxyContin helps more.
■ MD: Are you working? If not, I bet you want to get back to work.
■ Patient: I am on Disability (Social Secruity).
■ MD does examination: calls out: normal muscle tone, decreased ROM, no sensory loss. I see your old MRI
showed bulging discs.
■ MD: I think you may have a pinched nerve. Lets get a new MRI of your neck and an EMG. I recommend we
get a UDS. I would like to schedule an epidural steroid. Here is some information on SCS to look at also.
■ Patient: Doc, UDS? What are you saying?
27
New Patient: Accepted Shoulder Claim
You are 43 years old, a carpenter, and your shoulder
has been hurting for 3 years. Is that correct?
It’s horrible! When I was in Cabo last week, it hurt
the whole time. I could hardly use it.
I noticed your tan. Where is the pain exactly?
It starts at my shoulder, then goes to my wrist.
I see you are on the Fenatyl patch, does it help?
It takes the edge off. The OxyContin helps more.
Are you working? If not, I bet you want to
get back to work.
I am on Disability.
I think you may have a pinched nerve. Let’s get a
new MRI of your neck and an EMG. I recommend
we get a UDS and schedule an epidural steroid.
28
Biopsychosocial Approach to Procedures
Be systematic
Clarify the Diagnosis
Coordinated and Appropriate Treatment
 Clinical assessment
 Treatment criteria
– Objective criteria for diagnosis
 Criteria for diagnostic testing
– Clear reasons for this test
 Careful interpretation (Danger)
– Common occurrence of incidental
findings
 Behavioral factors
– Catastrophizing, fear avoidance, self
efficacy, secondary gain
– Carefully selected
 Treatment effectiveness measures
– Subjective and objective
 Clear intervention criteria
– Increase or discontinue
 Behavioral interventions
– Set realistic expectations, accountability,
perspective
29
Chronic Pain Management Should Not Be Chaotic
A coordinated plan best serves the patient’s needs.
■ Appropriate
medications and
treatments
Inappropriate
treatments
Understanding
behavioral factors
and cognitive
behavioral
approach
Comprehensive, Individual Plan
30
The Role of Pain Management and Case Management
 Clarify the diagnosis (biopsychosocial assessment)
■
■
■
■
Clarify patient symptoms, location and circumstances
Administer pain questionnaires
Clarify the criteria for a given diagnosis
Identify early behavioral red flags, psychosocial factors
 Monitor medication use
■
■
■
■
■
Query all new medications
Compare with existing medications for redundancy and interactions
Educate patient on potential and existing side effects and toxicity
Assure proper monitoring is in place, use MED calculator
Coach patient on outcome measurement and realistic expectations
 Monitor all invasive intervention
■
■
■
Help determine if patient is the appropriate candidate
Assist patient in formulating questions regarding their goal, likely effectiveness and risks
Coach patient on outcome measurement and realistic expectations
 Help identify more effective and holistic chronic pain treatment options
■
■
■
■
Non-pharmacological care
Cognitive behavioral therapies
Interdisciplinary CPMP
Self-management
31
The Chronic Pain Toolbox
What is old
What is new
■ Discograms
■ Opioids with no ceiling dose
■ Opioids: high dose short-term opioids, stronger
opioids, state implementation of prescription
monitoring programs
■ Intradiscal electrotherapy
■ New molecules
■ Trial and error
■ Physician non-accountability
■ Therapeutic exercise-an old but goody
■
Analgesics and neuromodulators
■
Prialt, Ketamine
■
Topical agents
■ Laser back surgery, new electrical stimulation
devices , HBOT!
■ Rehabilitation: resurgence of CBT, functional
restoration, patient education and awareness
■ A greater emphasis on outcomes
■ Regulatory: guidelines, state pharmacy
management programs
32
The Challenges of Opioids
Are narcotics overused?
Common side effects and complications
Mitigation strategies
■ Dependence, addiction, misuse and death
■ Universal precautions
■ OIH
■ Dosage guidelines
■ Hormonal disorders
■ Morphine equivalent dose
■ Urinary dysfunction
■ State prescription monitoring program
■ Constipation
■ Nausea
■ Fatigue
■ Diversion
33
Universal Precautions
■ Make a Diagnosis With Appropriate Differential
following a comprehensive evaluation.
■ Reassessment of Pain Score and Level of
Function.
■ Psychological Assessment, Including Risk of
Addictive Disorders and stratification.
■ Regularly Assess the "A's" of Pain Medicine
(analgesia, activities of daily living, adverse side
effects, and aberrant drug-taking behaviors);
"adherence" and "affect (observed mood) might
also be added.
■ Informed Consent.
■ Treatment Agreement.*
■ Pre- or Post Intervention Assessment of Pain
Level and Function.
■ Appropriate Trial of Opioid Therapy With or
Without Adjunctive Medication.
■ Urine Toxicology*
■ Periodically Review Pain Diagnosis and Comorbid
Conditions, Including Addictive Disorders.
■ Documentation.
Universal Precautions in Pain Medicine, which experts in pain medicine recommend
be used with all pain patients. Authors: Gourlay DL, Heit HA, Almahrezi A. 2005.
Source: Pain Medicine
34
Restoration of Function
Disturbance of function, not pain, is what ultimately causes disability
■ Restoration of function: the concept
■
Rehabilitation should be the goal of all pain management interventions = return to optimal function
■
What is function? (World Health Organization, International Classification of Function)
■
Studies repeatedly show that when you uncouple pain and function, function can dramatically improve
■ Objective measures
■
Measurement that is not subjective, not dependent on effort
■
Blood pressure, temperature, pulse, range of motion, calf measurement, reflexes, strength, gait
■ Functional measures examples (ODG 2012)
–
Work Functions and/or Activities of Daily Living, Self Report of Disability (e.g., walking, driving,
keyboard or lifting tolerance, Oswestry, pain scales, return-to-work, etc.)
–
Physical Impairments (e.g., joint ROM, muscle flexibility, strength, or endurance deficits)
–
Approach to Self-Care and Education (e.g., reduced reliance on other treatments, modalities, or
medications, such as reduced use of painkillers)
35
The Business of Chronic Pain
Buyer beware
■ Rush to market promoted by for-profit drug and technology companies
■ FDA approval does not = effective or safe
■ To get FDA approval, you only need to submit 2 studies showing it is better than placebo, no matter how
many studies show it is not (1)
■ Rampant off label use; lack of careful selection
■ Shift in physician training opportunities to procedural opportunities-glut of providers
■
Physical Medicine and Rehabilitation experience
■ Direct marketing to patients
■ Lack of regulation seen in other areas of medicine
■
Compare to acute care, core measures (Diabetes management, CHF management)
■
Lack of outcome measures or expectations (acute care cardiac success rates, CEA, complication rates)
1. The New York Review of Books, The Epidemic of Mental Illness: Why?; June 23,
2011; Marcia Angell
36
When the claims approach does not work…
Identify when the usual process is allowing care to splinter
■ What happens when the usual adjudication
process does not work
■
The injured worker gets opposite
messages from doctor than from UR
■
The injured worker becomes more and
more alienated; iatrogenic disability
■ Solutions
■
Systematic approach
■
Medical case management action team
■
A collaborative approach
■
Understand the bigger picture:
biopsychosocial model
■
Seek first to understand
■
Get everyone on the same page
■ Red flags
■
Delayed return to work
■
Getting worse rather than better
■
Crescendo of requests
■
Anger and alienation
37
Pain Management Philosophy
Expert, effective pain management involves a biopsychosocial, evidence-based
foundation.
Systematic Care Management SM
Peer and Case Management
Experts
Analytics
Bio
Social
Clarification
of Diagnosis
Centers of Excellence
Psych
Coordination
of Care
Pain Behavior
Intervention
Evidence-Based Medicine
Functional Restoration Approach
Cognitive-Behavioral Techniques
Accurate diagnosis
Evidence Supported Care
Less Reliance
38
Physicians Can Be
Deceived
“Actors were identified as the standardized
patients around 10% of the time.”
Physicians Being Deceived; Beth Jung MD, Pain Medicine Volume 8, Number 5, 2007
Key Take-Home Lessons on Chronic Pain
By the end of this presentation, you should understand the importance systematic
management
 Objective assessment and criteria
■ ROM, strength, sensation, movement, gait…
 Careful Selection
■ Is this test or treatment proven appropriate to
this type of patient in this circumstance
 Avoid trial and error
■ Just “trying” is a set up for failure, placebo
 Measure effectiveness
■ There should be a meaningful functional
measure
 Withdraw treatments that are not
effective
 Perspective and context
40