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What Every Physician Needs To Know About
Pain
Kevin Cuccaro, D.O.
StraightShotHealth.com 1
Learning Objectives
• Assess & critique commonly prescribed therapies for chronic
pain.
• Describe the three components of the “Pain Experience.”
• Develop a management plan that addresses risk factors
involved in the development & maintenance of chronic pain.
StraightShotHealth.com 2 Kevin Cuccaro, D.O.
Background
• D.O.
• Anesthesiologist
• Fellowship trained Pain Physician
• Military & Civilian Experience
• Am I Helping People Get Better?
3 Kevin Cuccaro, D.O. StraightShotHealth.com
“Why Should I Care About Pain?”
(“Don’t we have specialists for this?”)
Kevin Cuccaro, D.O. StraightShotHealth.com 4
“Life is Pain, Highness. Anyone who says differently is selling
something.”
The Princess Bride (1987)
Kevin Cuccaro, D.O. StraightShotHealth.com 5
A World of Pain
• Common Symptom
• Most Common Disability
• $600+ Billion Annually
• 100 Million Americans (*)
Back Pain
• 2nd Most Common Reason for
ALL physician Visits
• Lifetime Prevalence of 60 – 90%
• Industrialized & Developing
World
• Disability rates very different
Kevin Cuccaro, D.O. StraightShotHealth.com 6
How We Treat It…
What We Do …
• Increased MRI’s 307+%
• Increased Injections 130-
700+%
• Increased Surgeries 300+%
• Increased Opioids 690+%*
But What Do We
Get?
Kevin Cuccaro, D.O. StraightShotHealth.com 7
Imaging
• Problems noted since 1976
• Wide Geographic Variation
• Increasing Use, Increasing Costs …
• Outcomes Worse
8 Kevin Cuccaro, D.O. StraightShotHealth.com
‘Early’ Imaging
• No Increase in Quality of Care
• Longer Disability, Increased Rx Use.
• Mixed Patient Satisfaction
• Patient Anxiety*
9 Kevin Cuccaro, D.O. StraightShotHealth.com
Anxiety With Imaging
• ‘Abnormal’ Findings are Common
• Disc Change in Youth
• Bony Change Normal with Age
• Majority of Findings are ‘Normal’
• Label & Reinforce Organic Pain Beliefs
10 Kevin Cuccaro, D.O. StraightShotHealth.com
Surgery in the U.S.
• Highest Rates In The World
(& Increasing)
• Complex Sx Increasing
– 15X 5 years
– 3X Costs
– 50+ % ‘Unnecessary’
– (33% ‘Wrong’)
• Geographic Variation
– 8-20X
• ‘Best’ Sx Outcomes…
– Where rates are lowest!
Kevin Cuccaro, D.O. StraightShotHealth.com 11
Who Needs Surgery?
Major Neurologic Deficits
Major Spine Trauma
Fusion For Pain?
“No subset of patients with chronic
LBP could be identified for whom
spinal fusion is a predictable and
effective treatment “
(Biomechanical)
Kevin Cuccaro, D.O. StraightShotHealth.com 12
Injections For Pain
• Practitioners
• Use
• Costs
• Geographic Variation
– 7.7 X (State)
– 18.4X (City)
Effective? (Guidelines)
Those Who Get Paid To Do Them…
• Nerve Blocks – Yes
• ‘Burning’ Nerves – Yes
• Disc Treatments – Yes/No
• Epidural – Yes
Those Who Don’t…
• Nerve Blocks – No
• ‘Burning’ Nerves – No
• Disc Treatments – No
• Epidural – Limited
14 Kevin Cuccaro, D.O. StraightShotHealth.com
Most Common Arguments For Use…
“ Use of Drugs…”
“Prevent Surgery…”
“ Pain…”
Rates of Opioid Use
Rates of Surgery
No Difference
(Effect on Risk Factors?)
15 Kevin Cuccaro, D.O. StraightShotHealth.com
Opioids & Chronic Pain
• 1996 APS/AAPM Consensus Statement on Pain
• Pain Undertreated
• Effective in treating Chronic Non-Cancer Pain
• Risks of Addiction & Abuse Low
What Happened Next?
What Followed Sales?
The United States
Population
Rest ofWorld
UnitedStates(4%)
Opioid Consumption
Rest ofWorld
UnitedStates(80%)
Kevin Cuccaro, D.O. StraightShotHealth.com 19
Opioids & Chronic Pain
What Was Said…
• Work Well for Chronic Pain
• Little Tolerance
• Low Risk of Abuse
• No Ceiling
What Was Found…
• No Studies >16 weeks
• Data from Acute Pain
• Studied w/o Comorbidities
• High Risk of Abuse
• Do Not ‘Eliminate’ Pain
Opioids & Chronic Pain
What Was Said…
• Improve Function & Quality
of Life
• Retain or Return to Work
• Retain Cognition, Dexterity,
Reaction times…
What Was Found…
• No Clear Evidence
• No Evidence
• Maybe IF
– Unchanged Dose…and No
Other Impairments Present
Other Problems…
• Endocrinopathy
• Respiratory Depression
• Sleep Disturbance
• Sudden Death & Cardiac Toxicity
• Diversion & Societal Harm
2001-10 The Decade of Pain Control
What We Did…
• MRI’s 300%
• Injections 130-700+%
• Surgeries 300+%
– (15X for Complex)
• Opioids 690+% (sales)
– 1,448% (GPP)
What We Got…
• Disability Rates Increasing
• Complication Rates
Increasing
• No Improvement in Self
Reports
• Costs Continue to Escalate
Kevin Cuccaro, D.O. StraightShotHealth.com 23
Overall Results…
2000
US Pop. 282 Million
45 Million Chronic Pain
2010
US Pop. 309 Million
(9.6%)
100 Million Chronic Pain
(122%)
Kevin Cuccaro, D.O. StraightShotHealth.com 24
Why? What Are We Treating?
How Should We Treat It?
25 Kevin Cuccaro, D.O. StraightShotHealth.com
What Are We Treating?
“Pain is an unpleasant sensory &
emotional experience associated with
actual or potential tissue damage or
described in terms of such damage.” IASP 1994
26 Kevin Cuccaro, D.O. StraightShotHealth.com
The Neurobiology of Pain
• Sensory-Discriminative
• Affective-Motivational
• Cognitive-Evaluation
• Sensation (Transmission)
• Emotion (Meaning)
• Cognition (Attention &
Response)
27 Kevin Cuccaro, D.O. StraightShotHealth.com
Pain Is A Process…
Fire Pain
28 Kevin Cuccaro, D.O. StraightShotHealth.com
Acute Pain Experience
• > Peripheral
– i.e. Nociceptive
– (But Not Always)
• “Broken Leg”
• Cut, Poke, Drug
Kevin Cuccaro, D.O. StraightShotHealth.com 29
Cognition
(Brain)
Emotion
(Brain)
Pain
Experience
Sensation
(Body)
Chronic Pain Experience
• > Central
– (Can Cause Peripheral Δ’s)
• “Fibromyalgia” (& Chronic
Back Pain)
• Peripheral Tx Poor
Kevin Cuccaro, D.O. StraightShotHealth.com 30
Cognition
(Brain)
Emotion
(Brain)
Pain
Experience
Sensation
(Body)
All Pain Has 3 Components Broken Leg
Cognition
(Brain)
Emotion
(Brain)
Pain
Experience
Sensation
(Body)
FMS or Chronic Back Pain
Cognition
(Brain)
Emotion
(Brain)
Pain
Experience
Sensation
(Body)
Kevin Cuccaro, D.O. StraightShotHealth.com 31
What Is This?
Kevin Cuccaro, D.O. StraightShotHealth.com 32
?
Sensation
(Transmission)
Nociception ≠Pain!
Nociception
• Nerve stimulation that
conveys information about
potential tissue damage to
the brain.
• Anesthesia INDEPENDENT
• OBJECTIVE
Pain
• Perception & Response of
Sensory Information
• Genetics, prior learning,
current psychological status
& sociocultural influences
• Anesthesia DEPENDENT
• SUBJECTIVE
Why Is This Important?
Chronic Acute
Kevin Cuccaro, D.O. StraightShotHealth.com 34
Examples
• Context
– Threat
– Accidental vs.
Intentional
• Meaning
– Abdominal Pain
• Learning
– Snake Bite
• Emotion
– Anxiety
– Anger
• Sensation Δ
– Epidural
Kevin Cuccaro, D.O. StraightShotHealth.com 35
Great…Now What?
(How Should We Treat It?)
Kevin Cuccaro, D.O. StraightShotHealth.com 36
What Are The Risk Factors?
• Genetic
• Epigenetic
• Developmental
– Childhood Illness, Abuse, Neglect
• Adult Victimization/PTSD
• Psychosocial
– Chronic Social Stress
– Low Social Support
– Acute Stressors
• Psychiatric Comorbidities
• Pain Intensity
• Pain Beliefs
• Maladaptive Coping
• Nonorganic Signs
• High Baseline Impairment
• (What’s Missing?)
Kevin Cuccaro, D.O. StraightShotHealth.com 37
Positive Outcomes?
• Pain Beliefs
(Fear Avoidance)
• Coping Strategies
– Passive Active
• Pain Self-Efficacy
• Psychological Distress
Not With…
Imaging
‘Satisfactory Fusion’
Passive Coping
Kevin Cuccaro, D.O. StraightShotHealth.com 38
Three Primary ‘Pain Targets’
Beliefs
Coping
Self-Efficacy
Kevin Cuccaro, D.O. StraightShotHealth.com 39
Beliefs That Pain
• Fear Avoidance
– ‘Hurt’ = ‘Harm’
– Avoidance of Activity
– Kinesiophobia
• Catastrophizing
– Rumination
– Helplessness
– Magnification
• ‘Organic’ Pain Beliefs • Persistent pain is the result of damage to tissues of the body
• Physical exercise makes the persistent pain worse
• It is impossible to do much for oneself to relieve persistent
pain
• Persistent pain is a sign of illness
• Experiencing persistent pain is a sign that something is
wrong with the body
• It is Impossible to control your own persistent pain
• Being in persistent pain prevents you from enjoying hobbies
and social activities
• The amount of persistent pain is related to the amount of
damage.
Kevin Cuccaro, D.O. StraightShotHealth.com 40
‘Organic’ Pain Beliefs
– Structural Focus
– Imaging Reinforcement
– Negative Future
Outlook
– Worse Outcomes
– Iatrogenic*
O’Sullivan P, Lin I. Acute low back pain: Beyond drug therapies. Available at:
http://www.pain-ed.com/. Accessed March 25, 2015.
Waddell G - Spine (1987) 1987 Volvo award in clinical sciences. A new clinical model for the
treatment of low-back pain.pdf
Allan DB, Waddell G. An historical perspective on low back pain and disability. Acta Orthop
Scand Suppl. 1989;234:1-23.
Lin IB, O'sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back
pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open.
2013;3(4)
Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what
clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527-34.
Zusman M. Belief reinforcement: one reason why costs for low back pain have not
decreased. J Multidiscip Healthc. 2013;6:197-204.
Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between
health care professional attitudes and beliefs and the attitudes and beliefs, clinical
management, and outcomes of patients with low back pain: a systematic review. Eur J Pain.
2012;16(1):3-17.
Kevin Cuccaro, D.O. StraightShotHealth.com 41
Words That Harm Or Heal
Harmful
• Structural Scapegoat
– “You have disc degeneration, etc.”
• Prolong Fear
– You should avoid…”
• False Prophecy
– “Your back will wear out..”
• Hurt = Harm
– “Let pain guide you…”
Helpful
• Discuss Pain*
– “Back pain is not ‘damage’”
• Promote Resilience
– “The back is strong…””
• Promote movement
– “Motion is lotion…”
• ‘Frame’ Imaging
– “Your MRI shows wrinkles…”
• Self-Management*
– “Let’s create a plan to help you help
yourself…”
Kevin Cuccaro, D.O. StraightShotHealth.com 42
Coping & Pain
Passive Coping
• Avoidant behaviors
• “It’s awful & I can’t do anything!”
• ‘External’ reliance for solution or
relief.
• Reactive
Active Coping
• Engaged behaviors
• Reliance on self
• Social Support (w/o drowning)
• Humor
• Proactive
Kevin Cuccaro, D.O. StraightShotHealth.com 43
What Coping Style Is Reinforced?
• Cut, Poke, Drug
• Physical Therapy
• Behavioral Health
• Groups
• Acupuncture, etc.
• Passive
• Mixed
• Active
• Active*
• Passive
Kevin Cuccaro, D.O. StraightShotHealth.com 44
Self-Efficacy
Individual’s perception…
they can carry out a specific action…
…when challenged.
Kevin Cuccaro, D.O. StraightShotHealth.com 45
Sources Self-Efficacy
‘Mastery Experiences’
– Overcoming obstacles
through persistent effort.
Role Models
– Seeing people similar to
oneself succeed by sustained
effort.
• Social Persuasion
– Peer group that persuades &
encourages*
• Eustress Not Distress
– Improved stress &
interoceptive management
Kevin Cuccaro, D.O. StraightShotHealth.com 46
Goals of Treatment
Ideal
• Develop & Reinforce
Positive Beliefs
• Encourage & Reinforce
Active Coping
• Teach & Reinforce Self-
Management
No Harm
• Do Not Contribute To Bad
Beliefs
• Do Not Promote Passive
Coping
• Do Not Decrease Self-
Efficacy
Kevin Cuccaro, D.O. StraightShotHealth.com 47
How To ‘Manage’ Pain.
• Rule out “Badness”
• What Else On Problem
List?
• Over- vs. Under-treatment
– Downstream Effects
• Focus on Function
• Encourage & Engage
• Find the “Bright Spots”
• Scheduled follow up *
• Behavioral Health
• More Coach…Less Genie
Summary
Crisis of Pain…
…Management
– Imaging
– Surgery
– Injections
– Drugs
Pain Is A Process…Like Fire
– Nociception ≠Pain
– Risk Factors Are
Psychosocial
– Focus On Biomechanical
Kevin Cuccaro, D.O. StraightShotHealth.com 49
The Decade of Pain Control & Research
US Pop. 9.6%
Chronic Pain 122%
Kevin Cuccaro, D.O. StraightShotHealth.com 50
Last Words…
Kevin Cuccaro, D.O. StraightShotHealth.com 51
Questions or Comments?
Kevin Cuccaro, D.O. StraightShotHealth.com 52
True or False
• There are two types of pain—Emotional &
Physical.
• Injections for back pain reduce chronic opioid
consumption.
Kevin Cuccaro, D.O. StraightShotHealth.com 53
Selected Bibliography Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med. 2012;2(1):106-16.
Garland EL. Pain processing in the human nervous system: a selective review of nociceptive and biobehavioral pathways. Prim Care. 2012;39(3):561-71.
Mularski RA, White-chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med.
2006;21(6):607-12.
The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591-608.
Mehta N. Mind-body Dualism: A critique from a Health Perspective. Mens Sana Monogr. 2011;9(1):202-9.
Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. The Lancet. 2011;377(9784):2226-2235.
Villemure C, Schweinhardt P. Supraspinal pain processing: distinct roles of emotion and attention. Neuroscientist. 2010;16(3):276-84.
Wiech K, Tracey I. The influence of negative emotions on pain: behavioral effects and neural mechanisms. Neuroimage. 2009;47(3):987-94.
Willems PC, Staal JB, Walenkamp GH, De bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J.
2013;13(2):99-109.
Zale EL, Lange KL, Fields SA, Ditre JW. The relation between pain-related fear and disability: a meta-analysis. J Pain. 2013;14(10):1019-30.
Kevin Cuccaro, D.O. StraightShotHealth.com 54
Selected Bibliography Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline
from the American Pain Society. Spine. 2009;34(10):1066-77.
Chou R, Shekelle P. Will this patient develop persistent disabling low back pain?. JAMA. 2010;303(13):1295-302.
Garland EL. Pain processing in the human nervous system: a selective review of nociceptive and biobehavioral pathways. Prim Care. 2012;39(3):561-71.
Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med. 2012;2(1):106-16.
Burns JW, Quartana P, Bruehl S. Anger suppression and subsequent pain behaviors among chronic low back pain patients: moderating effects of anger regulation style. Ann
Behav Med. 2011;42(1):42-54.
Burns JW, Holly A, Quartana P, Wolff B, Gray E, Bruehl S. Trait anger management style moderates effects of actual ("state") anger regulation on symptom-specific
reactivity and recovery among chronic low back pain patients. Psychosom Med. 2008;70(8):898-905.
Burns JW, Quartana PJ, Bruehl S. Anger management style moderates effects of attention strategy during acute pain induction on physiological responses to subsequent
mental stress and recovery: a comparison of chronic pain patients and healthy nonpatients. Psychosom Med. 2009;71(4):454-62.
Burns JW, Quartana P, Gilliam W, et al. Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model.
Health Psychol. 2008;27(5):645-52.
Kevin Cuccaro, D.O. StraightShotHealth.com 55
Selected Bibliography Manchikanti L, Hansen H, Pampati V, Falco FJ. Utilization and growth patterns of sacroiliac joint injections from 2000 to 2011 in the medicare population. Pain Physician.
2013;16(4):E379-90.
Manchikanti L, Pampati V, Singh V, Falco FJ. Assessment of the escalating growth of facet joint interventions in the medicare population in the United States from 2000 to
2011. Pain Physician. 2013;16(4):E365-78.
Manchikanti L, Pampati V, Falco FJ, Hirsch JA. Assessment of the growth of epidural injections in the medicare population from 2000 to 2011. Pain Physician.
2013;16(4):E349-64.
Manchikanti L, Helm S, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):ES9-38.
Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.
Nyström B. Spinal fusion in the treatment of chronic low back pain: rationale for improvement. Open Orthop J. 2012;6(1):478-81.
Paulus MP, Stein MB. An insular view of anxiety. Biol Psychiatry. 2006;60(4):383-7.
Phillips K, Clauw DJ. Central pain mechanisms in chronic pain states--maybe it is all in their head. Best Pract Res Clin Rheumatol. 2011;25(2):141-54.
Picavet HSJ. Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low Back Pain. American Journal of Epidemiology. 156(11):1028-1034.
Roy M, Lebuis A, Peretz I, Rainville P. The modulation of pain by attention and emotion: a dissociation of perceptual and spinal nociceptive processes. Eur J Pain.
2011;15(6):641.e1-10.
StraightShotHealth.com 56 Kevin Cuccaro, D.O.
Selected Bibliography Shibasaki, H. (2004). Central pain mechanisms. In: M. Hallet, L. H. Phillips, & D. L. Schommer (Eds.), Advances in Clinical Neurophysiology (pp. 39–48). Elsevier B.V.
Clauw DJ, Arnold LM, Mccarberg BH. The science of fibromyalgia. Mayo Clin Proc. 2011;86(9):907-11.
Lin CW, Mcauley JH, Macedo L, Barnett DC, Smeets RJ, Verbunt JA. Relationship between physical activity and disability in low back pain: a systematic review and meta-
analysis. Pain. 2011;152(3):607-13.
Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care. 2013;51(10):870-8.
Dunn KM, Jordan KP, Croft PR. Contributions of prognostic factors for poor outcome in primary care low back pain patients. Eur J Pain. 2011;15(3):313-9.
Edwards TM, Stern A, Clarke DD, Ivbijaro G, Kasney LM. The treatment of patients with medically unexplained symptoms in primary care: a review of the literature. Ment
Health Fam Med. 2010;7(4):209-21.
Friedly J, Standaert C, Chan L. Epidemiology of spine care: the back pain dilemma. Phys Med Rehabil Clin N Am. 2010;21(4):659-77.
Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581-
624.
Izard CE. The Many Meanings/Aspects of Emotion: Definitions, Functions, Activation, and Regulation. Emotion Review. 2(4):363-370.
Jacobs WC, Van der gaag NA, Kruyt MC, et al. Total disc replacement for chronic discogenic low back pain: a Cochrane review. Spine. 2013;38(1):24-36.
Kevin Cuccaro, D.O. StraightShotHealth.com 57
Selected Bibliography Kroenke, K. (2003). The interface between physical and psychological symptoms. Primary Care Companion J Clin Psychiatry, 5(suppl 7), 11-18.
Lumley MA. The two views of emotion in psychosomatic research. J Psychosom Res. 2010;68(3):219-21.
Lumley MA, Cohen JL, Borszcz GS, et al. Pain and emotion: a biopsychosocial review of recent research. J Clin Psychol. 2011;67(9):942-68.
Berna C, Leknes S, Holmes EA, Edwards RR, Goodwin GM, Tracey I. Induction of depressed mood disrupts emotion regulation neurocircuitry and enhances pain
unpleasantness. Biol Psychiatry. 2010;67(11):1083-90.
Carreon LY, Glassman SD, Howard J. Fusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and
MOS Short Form-36 outcomes. Spine J. 2008;8(5):747-55.
Chou R, Atlas SJ, Loeser JD, Rosenquist RW, Stanos SP. Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse?. J Pain.
2011;12(8):833-9.
Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice
Guideline. Spine. 2009;34(10):1094-109.
Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-30.
Olsen Y, Daumit GL. Chronic pain and narcotics: a dilemma for primary care. J Gen Intern Med. 2002;17(3):238-40.
Kevin Cuccaro, D.O. StraightShotHealth.com 58