CHRONIC PAIN SYNDROME AND INTERDISCIPLINARY EVIDENCE-BASED TREATMENTNicolle C. Angeli, PhD

Clinical Psychologist

Chronic Pain Rehabilitation Program

James A. Haley VA Hospital

DISCLOSURE STATEMENT

No conflicts of interest to disclose Acknowledgement that some content for this

presentation was borrowed from previous presentations by my supervisor and national pain expert, Dr. Jennifer L. Murphy, with her permission

Acknowledgement for assistance with the presentation of treatment outcomes from Dr. Evangelia Banou.

OVERVIEW & OBJECTIVES

Presentation will focus on an overview of chronic pain, the nature of interdisciplinary, chronic pain rehabilitation, and specifically

treatment at the James A Haley VAMC.

Objectives: Learn about chronic pain syndrome Appreciate indications for interdisciplinary

chronic pain rehabilitation. Understand treatment outcomes and evidence-

base of interdisciplinary chronic pain rehabilitation.

THE PROCESS OF PAIN: FROM ACUTE TO CHRONIC LOW BACK

PAIN

Fortunately, most individuals recover from episodes of acute LBP (Deyo, 1983).

50% in 2 weeks, 70% by 1 month, 90% by 3-4 months. (Mayer & Gatchel, 1988)

Unfortunately, beyond 3-4 months (now meeting the Chronic definition), full recovery is unlikely for the remaining 10%. 4

3-4 Months

Chronic

2 weeks

2 weeks

1 month

3-4 months

Ch

ron

ic

50%

20%

20%

10%

2 weeks

Ch

ron

ic

3-4 months

1 month

FROM CHRONIC PAIN TO CHRONIC PAIN SYNDROME

75%

25%

Most of the of individuals who develop chronic pain lead relatively normal lives

Portion of those with chronic pain develop Chronic Pain Syndromes (Klapow et al., 1993).

It is important to understand what makes one more likely develop chronic pain syndrome. 5

Chronic Pain

Chronic Pain Syndrome

Of the 10% with chronic pain

TRANSITION TO CHRONIC PAIN SYNDROME

Unrelated to pain intensity or physical severity of original injury (Epping-Jordan et al., 1998; Klapow et al., 1993).

Psychological variables (e.g., depression; somatic focus) and self-perceived disability consistently are the most accurate predictors of subsequent pain syndrome development (e.g., Fricton, 1996; Gatchel et al., 1995).

Development reflects a failure to adapt (Epping-Jordan et al., 1998).

6

RISK FACTORS FOR THE DEVELOPMENT OF CHRONIC PAIN

SYNDROME

Depression Low Activity High Pain Behavior Negative Beliefs Fear of Pain Substance abuse

Severe psychological stress or abuse

Age Job

dissatisfaction/blue collar/heavy physical work

Unemployment/ compensation

7

CHRONIC PAIN SYNDROMESYMPTOMS

Reduced activity Impaired sleep Depression Suicidal ideation Social withdrawal Irritability and Fatigue Strong somatic focus Memory and cognitive

impairment Misbehavior by

children in the home Less interest in sex

Relationship problems Pain behaviors Helplessness Hopelessness Alcohol abuse Medication abuse Guilt Anxiety Poor self-esteem Loss of employment Kinesiophobia 8

ROLE OF THE CHRONIC PAIN CYCLEIN CHRONIC PAIN SYNDROME

Reducing activity to minimize pain may help in the short term but leads to deconditioning over time and increased pain

Psychological, behavioral, and interpersonal problems develop or worsen as a result of inactivity/physical deconditioning

9

Pain PhysicalDeconditioning

PsychosocialDistress

OPIOIDS

Americans consume 80% of the global opioid supply and 99% of the hydrocodone supply (Manchikanti et al, 2010).

Beginning in 2009, drug-induced deaths exceeded motor vehicle deaths in the US.

From 1990 to 2010, the number of U.S. drug poisoning deaths involving any opioid analgesic more than quintupled.(CDC, 2010)

ER visits due to opioids doubled between 2004 and 2008. (CDC, 2010)

CURRENT CLIMATE OF CHANGE: DOD/VA

Prescription drug abuse doubled from 2002 to 2005 and almost tripled between 2005 and 2008 (Office of National Drug Control Policy, 2010).

In one study 22% reported pain medication abuse in the last year and 13% in the last 30 days (Bray et al, 2009).

Rx’s for pain medications written for military and veterans is up more than 438% since 2001 (National Council of Alcohol and Drug Dependence).

11.5% of military personnel reported prescription drug misuse compared to 4.4% in the civilian population (Office of National Drug Control Policy, 2010) .

The prevalence of prescription drug misuse among women in the military was a staggering 13.1%, more than four times the rate for civilian women (Office of National Drug Control Policy, 2010.)

Between 2009 and 2011, 72% of drug-related undetermined or accidental deaths involved prescription drugs (Tan et al, 2012).

OPIOIDS AND CHRONIC PAIN SYNDROME

Individuals use opioids for reasons other than pain, such as:Assisting with sleep initiation and

maintenanceDecreasing negative impact of

psychological factors such as depression and anxiety by emotional blunting

Inducing euphoric feelings/“high”

OPIOIDS AND SLEEP

Research indicates that opioids have negative impact on sleep time, efficiency, & REM (Dimsdale et al, 2007)

Recent literature suggests that chronic opioid therapy is related to sleep-related breathing disorders such as central sleep apnea

(Junquist et al, 2012) High doses of tramadol linked to insomnia

and reduction of REM sleep (Walder et al, 2001)

CHRONIC PAIN AND NEGATIVE AFFECT

Chronic pain related to negative affect (Fishbain et al, 1998) Depression Anxiety Bipolar Disorder Symptoms of anger, frustration, irritability (Fernendez

& Turk, 1995) According to one study, almost 90% of patients

who are referred to pain programs show evidence of at least one psychiatric disorder (Goli & Fozdar, 2002)

OPIOIDS AND NEGATIVE AFFECT

Those with chronic pain may be “chemical copers” as a way to deal with negative emotions

• May have history of using alcohol, other substances for similar purposes (past or current)

Opioids may be used to: Numb, escape, relax Cause mood elevation/euphoria

OPIOIDS AND NEGATIVE AFFECT

Further complicated by creation of cycle of opioid-induced positive mood followed by withdrawal effects such as dysphoria, restlessness, agitation

Opioids may then make the experience of negative affect even more unbearable while no coping skills have been developedPain Physical

Deconditioning

PsychosocialDistress

THE INTERDISCIPLINARY APPROACH:A PARADIGM SHIFT

As you can see, patients who experience chronic pain syndrome are often very complicated. Approaching treatment from one discipline IS NOT

EFFECTIVE There is no quick fix, there are no easy answers

– several disciplines must be involved in treatment for interventions to be effective in the long term

Biopsychosocial model of assessment and treatment is essential

17

THE INTERDISCIPLINARY APPROACH:BIOPSYCHOSOCIAL MODEL

BioPsychoSocial Complete

understanding of pain MUST take into account biological, psychological, and social factors.

Body and mind affect the other, often with negative cycle between the two.

Best treatment of chronic pain addresses all components.

BioMedicalPain is solely

explainable in biological or medical terms.

Emotional problems may result from chronic pain, but pain itself is entirely biological in origin.

The only truly effective treatment for pain involves medical approaches.

18

THE INTERDISCIPLINARY APPROACH:EMPIRICAL SUPPORT

According to the Institute of Medicine report, “Comprehensive and interdisciplinary (e.g., biopsychosocial) approaches are the most important and effective ways to treat pain.”

THE INTERDISCIPLINARY APPROACH:GENERAL EMPIRICAL SUPPORT

Meta-analysis of outcomes of 65 chronic pain programs by Flor et al (1992) reported: 20% average reduction in pain 45-73% reduction in opioid use 65% increased physical activity

Turk and Okifuji (1998) compared effectiveness of interdisciplinary treatment with TAU and found: Limited benefit for pain reduction Reduced medication use, emotional distress, and

healthcare utilization Increase in return to work and activity level

Scascighin et al, 2008 review of 27 RCTs found: Evidence of greater effectiveness compared with

untreated, conventional, or unimodal treatment Effectiveness lasting up to 13 years after treatment 20

THE INTERDISCIPLINARY APPROACH:NECESSARY PHILOSOPHY

Focus is NOT on pain reduction, focus is on improving quality of life

Provide education and promote acceptance: you have a chronic medical condition that cannot be fixed or cured… so NOW WHAT?

Learn how to live the best life that you can despite the pain

21

THE INTERDISCIPLINARY APPROACH:PAIN MANAGEMENT GOALS

How does the patient live the best life possible despite the pain? Through achieving these goals: Increase activity levels Decrease reliance on pain medications and other

passive modalities Learn active coping skills such as relaxation Increase socialization with others Improve mood

By facilitating these changes, functioning is improved across all domains

22

COMPREHENSIVE INTERDISCIPLINARY PAIN REHABILITATION PROGRAM

Who is appropriate for this approach?:More complex pain problems including those with

moderate to severe Chronic Pain SyndromeComplicating medical or psychological co-

morbidities that require closer monitoringHave failed other less intense treatment

interventions Have higher rates of problematic opioid useExperience high levels of emotional distressHave problems in their vocational functioningAre socially isolated and/or have relationship

problems 23

INTERDISCIPLINARY PAIN REHABILITATION PROGRAM:

INPATIENT VERSUS OUTPATIENT

Inpatient Most severe CPS Most complicated medical/psych co-morbidities Often opioid misuse and/or opioid dependent Often view treatment as last resort

Outpatient Slightly higher functioning More overall stability Must be able to do required activities on own May remain on low dose of opioids 24

PROS AND CONS:INPATIENT VERSUS OUTPATIENT

Inpatient Pros Best for long-distance

patients (60+miles) Sustained environmental

change, best way to develop new habits, ‘buy in’

Safe opioid titration, ability to monitor complex cases

Inpatients Cons More resources May not be best for

those with jobs, children, and daily responsibilities

Outpatient Pros Avoid lodging costs and

overnight staff More flexibility with

schedules Can integrate program at

home while in treatment

Outpatient Cons Much easier to

discontinue treatment, no-show, be noncompliant

Distance, weather, and other barriers to present 25

CHRONIC PAIN REHABILITATION PROGRAM:

TAMPA’S HISTORY

The Chronic Pain Rehabilitation Program began in 1988 as 4-bed inpatient unit housed on a general rehabilitation unit… added 2 more beds in 1991…became 12 beds in 1994 As the only inpatient program in the VA, we treat

veterans and active members from across the country Outpatient program added in 2009 Both CARF-Accredited

Inpatient since 1996 Outpatient since 2011 26

CHRONIC PAIN REHABILITATION PROGRAM:

STRUCTURE

Inpatient Program: 12 maximum census Local and long-distance 19 days, 18 nights Four admitted Monday morning week 1;

Four discharged Friday afternoon week 3 6-8 hours of treatment per day

Outpatient Program: 12 maximum census 3 days per week for 6 consecutive weeks Admit 2 per week 6-8 hours of treatment per day Implement program at home on off days

ADMISSION CRITERIA Medical and Psychological Screening

Local: Conducted during twice weekly clinics by team member in each area

Long distance: Medical record review is done and if cleared, a psychological phone screening is conducted

Admission Medically and physically capable of completing required

activities Psychologically stable – 3 months without

hospitalizations Not actively abusing alcohol or illicit drugs; if history, 3

months of documented abstinence No pending lawsuits directly related to primary pain

complaint (does not include SSDI or VA SC) For Inpatient CPRP: If using opioid analgesics or

muscle relaxants, willing to have those medications gradually discontinued while in program

For Outpatient CPRP: Encourage reduction of opioids and muscle relaxants encouraged

SAMPLE PATIENT Multiple pain locations Failed treatments Somatic focus Chronic opioid use Sleep apnea, Obesity, HTN, Diabetes Psychiatric co-morbidities: depression,

anxiety, irritability, personality disorders Social isolation & limited social support Limited physical & recreational activities;

significantly deconditioned Significant sleep disordersPAIN LEVEL DETERMINES ALMOST EVERYTHING

CHRONIC PAIN REHABILITATION PROGRAM:PROGRAM FRAMEWORK

All patients who enter on opioid analgesics and muscle relaxants are tapered off completely during course of treatment using a pain cocktail approach

Overall Cognitive Behavioral Therapy approach with goals of: Increased functioning across all domains Improved quality of life Reduction of pain level if possible

WHY COGNITIVE BEHAVIORAL THERAPY FOR CHRONIC PAIN?

Pain problems are partially maintained or exacerbated by psychological factors

Psychological factors that impact pain presentation and severity require intervention and should be viewed as medically necessary components of effective pain management

Treatment should seldom involve an either/or of physical versus mental health carePain

PhysicalDeconditioning

PsychosocialDistress

COGNITIVE BEHAVIORAL THERAPY FOR CHRONIC PAIN : KEY COMPONENTS

Identify, challenge, correct cognitive distortions “This pain is killing me. It’s ruining my life. Nothing

helps and no one understands.” Learn, implement, practice relaxation

techniques Diaphragmatic breathing, PMR, visualization

Monitor physical activities, develop pacing Time-based pacing

Identify, increase pleasurable activities Recreation, hobbies, social activities

Anticipate obstacles for successful implementation Problem-solve

COGNITIVE BEHAVIORAL THERAPY FOR CHRONIC PAIN: BARRIERS TO TREATMENT

Only a small percentage of pain sufferers seek psychological carePain is solely a physical problemSocial stigmaMind and body are separate entitiesPsychological care not legitimate

Note: CBT-CP is an adjuvant to comprehensive medical management

Chronic Pain

Psychology

Medicine

Occupational Therapy

Physical Therapy

PsychiatryPharmacy

Recreation Therapy

Nursing

Social Work

Dietetics

Pool Therapy

Vocational Rehabilitatio

n

PAIN TEAM MEMBERS

INTERDISCIPLINARY PAIN PROGRAMS: TREATMENT COMPONENTS

Interdisciplinary treatment in outpatient and inpatient programs is intensive and includes an individualized program with these basic components: Daily heated pool therapy session Daily physical therapy with exercise program

completed twice per day Relaxation training sessions twice daily, once

with occupational therapist Group lectures 2 hours per day Recreational therapy daily Daily medical rounds Walking session twice daily Sessions with pain psychologist

CHARACTERISTICS OF MEDICATION USE

39% using daily opioids at admission

Average dose converted into morphine equivalent dose (MED)

Range for 221 in group was 6mg – 360mg MED per day, with average of 61mg per day

RESULTS

Both groups improved significantly from admission to discharge on ALL measures. Improvements in: Pain severity; ADLs; mobility; negative affect; vitality;

pain-related fear; catastrophizing; sleep. No differences in pain reduction by group.

Opioid-tapered patients improved at least as much as those not taking opioids on all measures.

For patients taking opioids, correlations between admission taper dose and admission/discharge pain ratings approached zero.

IMPLICATIONS FROM EVIDENCE

Opioid withdrawal DID NOT interfere with rehabilitation

Improvements are equal or greater for those on opioids at treatment initiation

Consideration should be given to different treatment modalities, such as formal interdisciplinary pain rehabilitation programs and the use of behavioral strategies

INPATIENT CHRONIC PAIN REHABILITATION PROGRAM FY13 OUTCOMES:10/01/2012-09/30/2013

83

915

14

31

At DischargePrimary Diagnoses:(167 participants) Back pain

Neck pain

Headache

Extremity pain

Other pain

100 % of participants wereNOT taking opioids at the time of discharge

IMPROVEMENT IN FUNCTIONING AT DISCHARGE

Pain Daily Activities Mobility Mood Sleep0

20

40

60

80

100

How many participants improved?

Outcome Domains

Num

ber

of

Part

icip

ants

Im

pro

vin

g

PERCENTAGE OF FUNCTIONAL IMPROVEMENT

Pain Daily activities Mobility Mood Sleep0

5

10

15

20

25

How much did participants improve?

Outcome Domains

Avera

ge P

erc

ent

Impro

vem

ent

FOLLOW-UP DATA

44

89

7

17

At Follow-upPrimary Diagnoses:

(85 participants)

Back pain

Neck pain

Headache

Extremity pain

Other pain

ADMISSION: 27.1% of participants were using opioidsDISCHARGE: 100% of participants were NOT using opioidsFOLLOW-UP: 91.8% of participants were NOT using opioids

IMPROVEMENT IN FUNCTIONING AT FOLLOW-UP

Pain Daily Activities Mobility Mood Sleep0

5

10

15

20

25

30

35

40

45

How many participants improved?

Outcome Domains

Num

ber

of

Part

icip

ants

Im

pro

vin

g

PERCENTAGE OF FUNCTIONAL IMPROVEMENT AT FOLLOW-UP

Pain Mobility Mood Sleep0

1

2

3

4

5

6

7

8

9

10

How much did participants improve?

Outcome Domains

Avera

ge P

erc

ent

Impro

vem

ent

KEYS TO PROGRAM SUCCESS

Team functioningDesignated personnel who are

committedClose, constant communicationConsistent message

Administrative support

QUESTIONS?