Chronic Pain: Finding a Different Path to Relief

Physician Overview Course…

• Today we will address:

• Who is your Pain Management Team?

• Pain Science

• What about Opioids?

• Why are medications not enough?

• What can I do to take control of my situation?

• What additional help can I get in the Chronic Pain Department?

• Discuss next steps:

• Schedule trainings

• Schedule appointments

VALLEJO PAIN MANAGEMENT

Psychologists:

Pat Dwyer, PhDSamia Estrada, PsyD

Pain Management Skills Introductory Training

Individual Physician Consultation:

Diparshi Mukherjee, DOVeronica Obodo-Eckblad, MD

Rodd Stockwell, MD

Physical Therapist:

Kristine Bade, PT, DPT, FAAOMPT, OCS

Lawrence Chang, PT, DPT, FAAOMPT

Pharmacists:

Andrea Nelson, PharmD

Your Pain Management Team:

Overview Class

YOU

VACAVILLE PAIN MANAGEMENT TEAM

Psychologist:

Jessica Lester, PsyD

Pain Management Skills Training

Physicians:Rodd Stockwell, MD

Veronica Obodo-Eckblad, MDConrad Schoenwald, DO

Physical Therapist:

Nikki Keffler-Roa, PT, DPT

Additional Resources

Pharmacists:

Grace Le, PharmD, BCACPKevin Miller, PharmD

Who is your Pain Management Team:

UNDERSTANDING PAIN

• What causes chronic pain?

• What can you do to help it?

DOES PAIN COME FROM MY TISSUES?

• What is Phantom Limb Pain?

• How could someone have foot pain when they have no foot?

• Pain ≠ Tissue damage

• Tissue damage ≠ Pain

• What makes your pains worse?

• Multisystem process

• A complex Mind/Body phenomenon

• Can ABSOLUTELY change

• Demonstrates Functional MRI Activity of the Brain before/after pain physiology discussion/education

Brain Scan of Personwithout Pain

Brain Scan After Pain Physiology Education

Person in Pain Before Pain Physiology Education RED = Pain

This is your brain on PAIN!!!

WHAT’S IN IT FOR ME?

• Reduction in frequency and intensity of pain flares

• Less pain and Increase in functionality

• Increase in sense of control

• Increase in quality of life

• Increase in understanding of pain

process

• Isn’t this the answer to my Pain Problem?

WHAT MEDICATIONS ARE OPIOID MEDICATIONS?

• Buprenorphine

• Butorphanol

• Codeine

• Fentanyl

• Hydrocodone

• Hydromorphone

• Meperidine

• Methadone

• Morphine

• Oxycodone

• Oxymorphone

• Tramadol

• Naltrexone and others…

LEGAL REQUIREMENTS OF YOUR MD IF YOU ARE RECEIVING OPIOID MEDICATIONS

• Face to face visit with them at least every 6 months

• Regular unannounced Urine Drug Testing

• Signed Opioid Agreement informing you of your risks

• Screening for misuse/abuse

• Screening for depression

• Monitoring for overuse

• Monitoring for diversion

• Safe Dosing Limits

Medications…

Inside your packet is a copy of the “Opioid Medication Agreement” If you are taking Opioids, you will need to read and sign that form when you meet with your Individual Chronic Pain Physician.

Your Primary Care Physician will continue to manage and fill your pain medications until you meet with one of our Physicians Individually.

We cannot fill/refill or take over any of your medications today.

YOU WILL FIND A SAMPLE VERSION OF OUR OPIOID AGREEMENT IN YOUR PACKET

THIS OUTLINES OUR RESPONSIBILITIES AND YOURS WITH REGARDS TO OPIOID MEDICATIONS.

Chronic Pain

OPIOID AGREEMENT: YOUR RESPONSIBILITIES

• Take your medication only as prescribed

• Inform the pain clinic if another doctor/dentist gives you additional opioid medications

• Keep your medications stored or locked up in a safe, secure place.

• We can not replace lost or stolen medication.

• Complete unannounced urine screening drug tests as requested

• Significantly limit use of alcohol when taking opioids

• DO NOT share opioid medications with others

• DO NOT use illegal, street drugs (cocaine, methamphetamine)

• DO NOT use cannabis (marijuana) along with your Opioids

• DO NOT drive or operate machinery when taking opioids until you can do so safely

HOW DID WE GET HERE???

• Prior to 20 years ago physicians limited opioids to a week after surgery or injury.

• Opioids were initially designed and studies for short term use only

• 20 years ago, in the US, physicians first started giving daily opioids for chronic pain.

• We didn’t know what damage chronic daily opioids would cause to someone’s body.—until now.

• The damage is much worse than we thought.

EVERYONES NOW EXAMINING THE USE OF OPIOIDS…

THE EXTENT OF THE US OPIOID EPIDEMIC

• The USA is 4.6% of the world’s population

• We use 80% of the world’s opioid supply

• We use 99% of the worlds Hydrocodone supply

• 91 people die each day in this country from an opioid related overdose

• Sources: CDC, NIDA, HHS

o i E u le Do )

March 26, 2020| © Kaiser Permanente 2010-2011. All Rights Reserved. 19

Interagency Guideline on Prescribing Opioids for Pain. Agency Medical Directors Group. 2015. 3rd edition. Accessed 2/21/16 via http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf

(M rph ne q iva nt se

MAXIMUM SAFER DAILY DOSES FOR CHRONIC PAIN

Daily Maximum of 50 Morphine Milligram Equivalents (MME):

• MS Contin (Morphine) 15mg up to 3 tabs/day

• Oxycodone (Percocet) 5mg up to 6 tabs/day

• Hydrocodone (Norco) 10mg up to 4.5 tabs/day

• Hydromorphone (Dilaudid) 2mg up to 6 tabs/day

• Fentanyl 12 mcg/hr patches q2-3 days

• Methadone 5mg up to 2 tabs/day

• Tramadol 50 mg up to 4 tabs per day

• Codeine up to 300 mg total per day

OPIOIDS: THE GOOD, THE BAD, THE UGLY AND THE UGLIEST!

The Good:

• Improve function

• Reduce pain

The Ugly:

• Tolerance

• Withdrawal symptoms

• Worsening of pain (Hyperalgesia)

• Sleep disturbance

• Hormone suppression

• Sexual disturbance

• Mood disturbance

• Immune suppression

• Endorphin Suppression

The Bad:

• Sleepiness

• Slow thinking

• Constipation

• Mental confusion

• Bad dreams or hallucinations

• Nausea and/or vomiting

• Itching

• Sweating

The Ugliest:

• Respiratory depression

• Overdose and Death

• Abuse/Addiction

• Harm to your health from misuse

• Impaired daily function

“...70% GREATER CHANCE OF DEATH FROM NON-OVERDOSE CAUSES…”

“Prescription of long-acting opioids for chronic noncancer pain, compared with anticonvulsants or cyclic antidepressants, was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose. “

JAMA 2016, Ray WA, et al, Prescription of Long-Acting Opioids and Mortality in Patients with Chronic NoncancerPain.

Is the risk worth it???

I KNOW THERE ARE RISKS, BUT WHAT ELSE CAN I DO?

A LOT!

THE THREE LEGGED STOOL OF CHRONIC PAIN MANAGEMENT

1. Passive Therapy

2. Active Therapy

3. Medication

Remember these THREE work together!!!Achieve better pain control by maximizing your benefits in each area!

PASSIVE THERAPY

• Surgery

• Injections

• Acupuncture

• Massage

• Chiropractic

• OMT

• May help fix a portion of your problem

• May provide temporary relief

• Is not the whole solution.

MEDICATIONS

• Opioids

• NSAIDS

• Skeletal Muscle Relaxants

• Neuropathic Medications

• Antidepressants

• Antiepileptics

• Other Medications

MEDICATIONS

• Don’t rely on just one type of medicine.

• The medications work best in combination

• Must balance benefits and side effects.

• Once you get on the ideal medicine

regimen for you, you will get up to a 30% pain reduction.

• If you want more pain reduction than this you will need to include passive and active therapies.

MARIJUANA –YES OR NO?

ACTIVE THERAPY

• Pacing:

• Breaking a large job into smaller pieces.

• So that when you are done your pains are not any worse than when you started.

• You train your body what is safe to do.

• There is more and more you can do without making your pains worse.

ACTIVE THERAPY

• Relaxation Skills:

• Stress makes many types of pains worse.

• The presence of stress hormones in your blood stream (Adrenaline and Cortisol) can augment pain.

• Physical stress and emotional stress are the same to your body.

• If you can’t avoid the stressor, then you can learn to relax your body to clear the stress hormones faster.

ACTIVE THERAPY

• Body Mechanics:

• This is NOT avoiding what you need to do in the day. IT IS changing how you will use your body to do it.

• How many different ways are there to pick up something off the floor?

• Learn the ways to use your body that hurt less and allow you to more?

ACTIVE THERAPY

• Daily Movement/Exercise:

• Stretching and Strengthening

• Overdoing your activity makes pains worse.

• Lack of activity makes pains worse.

• It takes some skill to find the middle ground.

• And to gradually build up your body’s fitness.

ACTIVE THERAPY – WE CAN TEACH YOU!

• Daily Movement/Exercise

• Stretching

• Strengthening

• Body Mechanics

• Relaxation Skills

• Behavior Change

• Pacing

• Sleep

• Education

Learn how to maximize the pain reduction with Active Therapy!

THE FIRST STEP

• You have already taken the first step in treatment!

• Education is treatment…that is WHY you are here!

• Your body will thank you for your attention, efforts and participation!

• Learn how to maximize the pain reduction with Active Therapy!

PAIN EDUCATION RESOURCES• The Mantra we have for Pain Education: Know Pain…Know GAIN!!!

• Online Pain Resources (YouTube)

• “Why Things Hurt” Lorimer Moseley (14 minutes)

• https://www.youtube.com/watch?v=gwd-wLdIHjs

• “Tame the Beast” Lorimer Moseley (5 mins)

• https://www.tamethebeast.org/#home

• Understanding Pain (Whiteboard Medical Animation: 5 mins)

• https://www.youtube.com/watch?v=ksNfgE3pVBw

REAL PATIENT RESULTS…

• “The past six months was the first time in a long time where my pain did not dictate my life choices. This is due to the skills, knowledge, and treatment I received from Kaiser’s Chronic Pain Program. The program is right to tell you they will not “fix” your pain, but instead will give you the skills to limit pain and deal with flare-ups. Through classes and doctor appointments, I learned new skills and was able to accept my pain, but not give into my pain. Mindfulness and relaxation has made pain episodes manageable. Through physical therapy skills I learned how to limit flare-ups and what to do when one hits. I am not afraid of pushing my body because I know how to properly ‘push’ my body. I could not be more thankful to the whole program and can say I have a much better quality of life thanks to the program.” ~ J.P.

REAL PATIENT RESULTS…• “…If anyone asks you if the chronic pain management program is helping

patients, please feel free to show my success story. The chart shows the amounts of medications I was on prior to joining the program. I have weaned off all medications except one, and we are continuing to taper down that one. I am grateful to you and the program and look forward to continuing my work and education in the upcoming advanced classes. This program has been a game changer and a life changer. Thank you for all your efforts and belief in those of us who need it most. ” ~ R.B.

Medication Tabs per day Now taking/day

MScontin 30mg 9 0

Soma 350mg 9 0

Diazepam 10mg 1-2 0

Flexeril 10mg 3 0

Percocet 10/325mg 12 3

Pain Department Overview

Ongoing Active Trainings:Body Mechanics, Tai Chi, Fitness, Mindfulness,

Yoga, Mind-Body Therapies, Rotating workshops

1-2x per week for 6-9 months

Introductory Training Once a week for 5 weeks

Physician Appointment

Psychologist Intake

VALLEJO PAIN MANAGEMENT: WHAT’S NEXT?

Physical Therapist Appointment