Interdisciplinary Chronic Pain Management

Sean Curran, BSc, MD, FRCP(C)Anesthesiologist, Credit Valley Hospital

Pain Management Unit, Hamilton Health Sciencescurransp@gmail.com

Disclosures

• none

Credentials

• Medical Doctor, University of Western Ontario

• Anesthesia, McMaster University

• Anesthesiology and Pain Management, Joseph Brant Hospital, Burlington

• Honourary Pain Fellow, FPM ANZCA, Royal North Shore Hospital, Sydney, Australia

• Pain Management, Hamilton Health Sciences

• Anesthesiology, Trillium Health Partners, Mississauga

Overview

• Cases

• History of interdisciplinary pain management

• Common elements

• Team members

• Admission criteria

• Program Comparisons

• Evidence

• Accessibility

Case 1

• Mr. C.K.

Case 3

• Mrs. J.W.

• 49 y.o. cardiac surgery for anomalous coronary artery

• IV-> compartment syndrome->fasciotomy

• Neuropathic arm pain

• Good function, mild depression

Case 2

• Mr. C. J.

• 54y.o. MVC--> back pain, headaches

• Medicalized (weekly back injections, physiotherapy, psychologist)

• Oxycodone

• Depression, suicidal thoughts, anxiety, agoraphobia, PTSD

• Functional impairment

Case 4

• Ms. A

• 37 y.o. from Somalia

• Widespread pain after MVC

• Depression, suicide attempt, auditory hallucinations

• Panic attacks, agoraphobia, PTSD, fearful, catastrophic thoughts

• Polypharmacy, benzodiazepine withdrawal, medication side effects

History

• Descartes 1664, Specificity Theory

History

• Chronic Pain

• Dualist paradigm

– Pathology: surgery, injection, medication

– Psychological

History

• Johnny “Bull” Walker

• 1941 NWA Light Heavyweight

Champion of the World

• Time magazine

– “founding father of pain

research and treatment”

History

• John Bonica, anesthesiologist

• 1942, MD, Marquette University

• 1953 Published “The Management of Pain”

• 1961 Multidisciplinary Pain Centre, University of Washington

• 1973 International Association for the Study of Pain (IASP)

• 2004 Professional Wrestling Hall of Fame

History: Bonica

• Integrated care

• Multiple health care professionals

• Restore function

• Alleviate pain if possible

• Improve pain management skills

History: Holistic

• Loeser 1980

Interdisciplinary Pain Management

• Comprehensive, co-ordinated team in same facility

• Biopsychosocial approach

• Common elements

– medication management

– graded physical exercise

– cognitive and behavioral techniques

Team Members

• Physician• Psychologist• Physiotherapist• Occupational Therapist• Social Work• Nursing• Pharmacist• Dietician• Administrative

Concepts

• Assessment

• Roles and Goals

• Education

• Pacing

• Relaxation

• Unhelpful thoughts

Education Topics

• Hurt vs. Harm• Healthy eating• Medication and sleep• Why your nervous system gets wound up• Acute vs. Chronic• Stress management• Self talk• Back and body care• Taking fitness home

CBT

• Instructions on relaxation, biofeedback, coping strategies, goal setting and changing maladaptive beliefs about pain

Pain'11; 152:S99-S106

CBT

Unpublished Doctoral Thesis, University of Leeds, UK; 2010

Admission Criteria

• Refractory pain

• Multidimensional impairments

• Reasonable goals

• Adequate grasp of English language

• Adequate cognitive function (ABI, dementia)

Exclusion Criteria

• Seeking cure or total analgesia

• Unstable medical conditions

• Substance abuse disorder

• Fall risk

Comparison

• ADAPT

– Sydney, Australia

– tough love

• CPMU

– Hamilton, Canada

– collaborative care

Evidence

• Flor et al

• meta-analysis of 65 studies, 3089 patients

• IPM vs no care, waiting list, medical management …

• Improved pain, activity, mood, health care utilization, medication intake

• Treatment effects maintained at 7 year follow up

Evidence

• Guzman et al

• Meta-analysis 10 RCTs CLBP

• Intensive (>100 hours) vs less intensive (<30)

• Strong evidence in support of intensive

Cost Effectiveness

Outcome Variable Interdisciplinary Conventional

Pain Reduction +/- +/-

Medication Reduction + -

Reduction of Emotional Distress

+ ?

Health Care Utilization + -

Iatrogenic Consequence + -

Activity/Return to Work + -

Closure of Disability Claims + ?

Critical Reviews in Physical and Rehabilitation Medicine 1998;10:181–208

Effect Size

Proc (Bayl Univ Med Cent). Jul 2000; 13(3): 240–243

Cost Comparison(millions USD)

Treatment Initial Subsequent 1 year post LifetimeDisability

Total

Interdisciplinary 142.6 25.3 197.1 1835.3 2200.4

Surgical 158.4 88.7 N/A N/A

Conventional 457.6 44.3 457.6 4226.8 5186.4

Okifuji et al, Handbook of Pain Syndromes. Mahwah, NJ: Lawrence Erlbaum Publishers,

1999:77–97

Evidence: Duration

• Patrick et al demonstrated lasting effects at 13 years

• Flor et al found results maintained 7 years

Accessibility

Pain Management Program

Canadian Journal of Anesthesia '07; 54(12):977–984

Chronic Pain Management Unit

• Chedoke Hospital, HHSC

• Intensive outpatient pain management program

• Psychologist, Registered Nurse, Occupational Therapists, Social Worker, Physiotherapist, Pharmacist, Dietician, Physicians