Transcript Pain Rehabilitation Center - Florida Alcohol and Drug Abuse

CHRONIC PAIN SYNDROME AND
INTERDISCIPLINARY EVIDENCEBASED TREATMENT
Nicolle 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

10%
20% 3-4
3-4
months
Months
1
month
20%

2
22
weeks
weeks
weeks 50%

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%.
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FROM CHRONIC PAIN TO CHRONIC PAIN
SYNDROME
Of the 10% with chronic pain

25%

Chronic Pain
Syndrome
Chronic Pain

75%
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.
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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).

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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/
7
compensation
CHRONIC PAIN SYNDROME
SYMPTOMS
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
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
ROLE OF THE CHRONIC PAIN CYCLE
IN CHRONIC PAIN SYNDROME
Reducing activity to
minimize pain may help
Physical
in the short term but
Deconditioning
leads to deconditioning
over time and increased
pain
 Psychological, behavioral,
and interpersonal
problems develop or
Psychosocial
Distress
worsen as a result of
inactivity/physical
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deconditioning

Pain
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
maintenance
 Decreasing 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 opioidinduced 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 developed

Pain
Physical
Deconditioning
Psychosocial
Distress
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

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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.

BioMedical
 Pain 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
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involves medical
approaches.
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
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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

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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
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COMPREHENSIVE INTERDISCIPLINARY
PAIN REHABILITATION PROGRAM

Who is appropriate for this approach?:
More complex pain problems including those with
moderate to severe Chronic Pain Syndrome
 Complicating medical or psychological co-morbidities
that require closer monitoring
 Have failed other less intense treatment interventions
 Have higher rates of problematic opioid use
 Experience high levels of emotional distress
 Have problems in their vocational functioning
 Are socially isolated and/or have relationship problems

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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
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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
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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 disorders
PAIN 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 care

Pain
Physical
Deconditioning
Psychosocial
Distress
COGNITIVE BEHAVIORAL THERAPY FOR
CHRONIC PAIN : KEY COMPONENTS

Identify, challenge, correct cognitive distortions


Learn, implement, practice relaxation techniques


Time-based pacing
Identify, increase pleasurable activities


Diaphragmatic breathing, PMR, visualization
Monitor physical activities, develop pacing


“This pain is killing me. It’s ruining my life. Nothing
helps and no one understands.”
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 care
Pain is solely a physical problem
 Social stigma
 Mind and body are separate entities
 Psychological care not legitimate

 Note:
CBT-CP is an adjuvant to
comprehensive medical management
PAIN TEAM MEMBERS
Psychology
Physical
Therapy
Occupational
Therapy
Pool Therapy
Social Work
Pharmacy
Dietetics
Chronic
Pain
Vocational
Rehabilitation
Psychiatry
Recreation
Therapy
Medicine
Nursing
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; painrelated 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
At Discharge
Back pain
Primary Diagnoses:
(167 participants)
Neck pain
Headache
31
14
83
15
9
100 % of participants were
NOT taking opioids at the
time of discharge
Extremity
pain
Other pain
IMPROVEMENT IN FUNCTIONING AT
DISCHARGE
Number of Participants Improving
How many participants improved?
100
80
60
40
20
0
Pain
Daily Activities
Mobility
Outcome Domains
Mood
Sleep
PERCENTAGE OF FUNCTIONAL
IMPROVEMENT
Average Percent Improvement
How much did participants improve?
25
20
15
10
5
0
Pain
Daily activities
Mobility
Outcome Domains
Mood
Sleep
FOLLOW-UP DATA
At Follow-up
Back pain
Primary Diagnoses:
(85 participants)
Neck pain
Headache
Extremity pain
Other pain
17
44
7
9
8
ADMISSION: 27.1% of participants
were using opioids
DISCHARGE: 100% of participants
were NOT using opioids
FOLLOW-UP: 91.8% of participants
were NOT using opioids
IMPROVEMENT IN FUNCTIONING AT
FOLLOW-UP
How many participants improved?
Number of Participants Improving
45
40
35
30
25
20
15
10
5
0
Pain
Daily
Mobility
Activities
Outcome Domains
Mood
Sleep
PERCENTAGE OF FUNCTIONAL
IMPROVEMENT AT FOLLOW-UP
How much did participants improve?
Average Percent Improvement
10
9
8
7
6
5
4
3
2
1
0
Pain
Mobility
Outcome Domains
Mood
Sleep
KEYS TO PROGRAM SUCCESS
 Team
functioning
 Designated personnel who are
committed
 Close, constant communication
 Consistent message
 Administrative support
QUESTIONS?