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PAIN AND THE BRAIN
Toward Integrative Mind-Body Interventions for the
Treatment of Chronic Pain in Veterans
Karen H. Seal, MD, MPH
Director, Integrated Pain Team
Director, Integrated Care Clinic for Iraq and Afghanistan Veterans
San Francisco VA Medical Center
University of California, San Francisco
OUTLINE
Chronic Pain:
• epidemiology, neuroscience, psychology
Biomedical Model
• focus on fixing the physical source of pain
Biopsychosocial Model
• multi-modal pain management
Integrative Model:
• emphasizes mind-body pain self-management
SCOPE OF THE PROBLEM
100 Million in U.S.
with Persistent Pain
Prevalence in Millions
120
100
100
80
 42% with pain lasting over
one year
 33% report pain as disabling
 Second most common
reason for outpatient visits
60
40
20
19
21
CHD
Diabetes
0
Chronic Pain
$600 Billion Annual Costs
 Healthcare expenses
 Lost income
 Lost productivity
American Academy of Pain Medicine www.painmed.org
Institute of Medicine. 2011 Relieving Pain in America. Washington D.C.
CHRONIC PAIN IN VETERANS
Most prevalent problem among US Veterans
75%
Female
Male
1.
2.
3.
4.
5.
50%
Vietnam
Iraq/Afghanistan
66%- 80% of Vietnam
veterans with PTSD
reported chronic
pain1,2
Veterans – carry heavy combat
equipment/body armor and
weaponry > 100 lbs
 Chronic pain more prevalent in
female OEF/OIF/OND vets3,4
 >50% with PTSD have received
chronic pain diagnoses5
Beckham, JC, et al. J Psychosom Res. 1997 Oct;43(4):379-89.
Shipherd, JC, et al. J Rehabil Res Dev. 2007;44(2):153-66.
Frayne, SM, et al. J Gen Intern Med. 2011 Jan;26(1):33-9.
Haskell, SG, et al. Pain Med. 2009 Oct;10(7):1167-73.
Seal KH. “PTSD in Combat Veterans: Exploring the Association with Chronic Pain and Prescription Opioid Use” American Psychological
Association, Annual Meeting, Honolulu, HI, July 31- Aug 4, 2013.
DEVELOPMENT OF CHRONIC PAIN
CHRONIC PAIN AND PTSD: MUTUAL MAINTENANCE
Disability
Pain
Anxiety/hyperarousal – pain perception
PTSD re-experiencing - evokes pain
Dysregulated ANS/Endog. Opioid system
PTSD
Anxiety
Adapted from Sharp TJ, Harvey AG. Clin Psychol Rev. 2001 Aug;21(6):857-77.
Biomedical Management of
Chronic Pain
BIOMEDICAL MODEL OF PAIN CARE
• Diagnostics to ID singular cause of pain
• Interventions target peripheral tissues
• Mind and body are separate
• Passive interventions
• Primarily mono-therapies
• “Kill the Pain”
• We can fix it!
• Complete pain relief is possible!
Butler, Neuro Orthopedic Institute WCPT 2011
PRESCRIPTION OPIOIDS & ADVERSE OUTCOMES
IN IRAQ AND AFGHANISTAN VETS
Receiving prescription opioids was associated with an increased risk
of adverse clinical outcomes, particularly in veterans with PTSD
 Wounds or
injuries
 Opioid-related
accidents and
overdoses
 Self-inflicted
injuries/Suicide
 Violence-related
injuries
Seal, KH, et al. JAMA. 20127.
BUT…..Are Opioids Really Effective Against Pain?
Noble, M. The Cochrane Collaboration. 2010
OPIOIDS AND CHRONIC PAIN-RISKS V. BENEFITS
• Uncertain Benefits:
• ? Pain relief
• ? Improved physical functioning, QOL
• Potential known harms:
•
•
•
•
•
•
•
•
Fatal overdose
Tolerance/physical dependence
Addiction/abuse/diversion
Respiratory depression--avoid in COPD
Cognitive impairment--avoid in dementia
Endocrine disruption- ED, muscle wasting, fatigue, OP
Sleep disturbances; worsening sleep apnea
Hyperalgesia on higher dose opioids
Biomedical To Biopsychosocial Model
CULTURAL TRANSFORMATION IN THE WAY PAIN
IS VIEWED, ASSESSED, AND TREATED
BIOPSYCHOSOCIAL MODEL OF PAIN
PAIN
Not just a symptom
but your patient’s lived experience
Pain
Functional
Disability
Psychosocial
GOALS OF CHRONIC PAIN MANAGEMENT
• Restore functioning
• Improve quality of life
• Reduce pain
“A car with four flat tires”
Medications only fill one tire
MULTIMODAL CHRONIC PAIN CARE
Gentle exercise
Manual therapies
Acupuncture
Yoga, Chigong
Others
CBT
Mood/trauma therapies
Substance abuse Tx
Sleep Hygiene
Meditation/Relaxation
Physical
Behavioral
SELF
MGT
NSAIDS
Anticonvulsants
Antidepressants
Topical agents
Others
Medication
Procedural
Nerve blocks/ablation
Steroid injections
Trigger point injections
Stimulators
SFVAHCS Integrated Pain Team
• Interdisciplinary care: MD, NP, pain
psychologist & pain pharmacist
• Biopsychosocial Model
• Optimize non-opioid pain care;
decrease opioid risk
• Improve function and QOL
• Dissemination to rural VA clinics
• Quality Improvement (QI) research
Gatchel et al., 2014; Wiedemer et al., 2007; Dorflinger et al., 2014
Integrative Chronic Pain Care
GROWING EVIDENCE BASE
INTEGRATIVE MODALITIES FOR PAIN
• Safer in patients with comorbidities and polypharmacy
• 30-50% of veterans use CAM/Integrative modalities;
only 1/3 disclose to their PCPs Smeeding et al., 2005
• Integrative modalities for pain are NOT available at
SFVAMC despite patient preference for CAM
INTEGRATIVE (CAM) THERAPIES—PAIN
National Center for Complimentary and Integrative Health http://nccam.nih.gov/health/pain/chronic.htm?nav=gsa
25
“Motion is the Lotion”
The good physician treats the disease; the great physician treats the patient who has
the disease. -Sir William Osler, circa 1900
© 2014 JPEP PAIN MANAGEMENT CURRICULUM
INTEGRATIVE PAIN MANAGEMENT STARTS WITH
VETERANS’ CORE VALUES AND FUNCTIONAL GOALS
40 y.o. vet with chronic pain and PTSD on high-dose opioids
• Focus on values: “What are some of the things you value
most in life?”
“Spending time with family; Supporting my family”
• Focus on functional goals: “Given what you value, what are
some things you would like to do if you were able to get your
pain under better control?”
“Camping and hiking in nature with family; finishing
school and getting a good job”
SHARED DECISION-MAKING
Integrative Pain Care Plan
Taper opioids (morphine) with pain pharmacist
so not overly sedated
Add topical creams and anti-inflammatories for
pain (instead of opioids)
Go to gentle yoga class to get more mobility and
strength and learn stress reduction
Start PTSD group at the San Francisco VA
Take a hike in nature on week-ends with family
SPECIAL THANKS!!
Integrated Pain Team and QI Staff: Sarah Palyo, PhD (Clinical Director);
Caitlin Garvey NP; Christina Tat, Pharm D; Erin Watson, PhD; Wilson Fong, NP;
Payal Marpara, PhD; David Villasenor, MD; Emily Sachs, PhD; Joe Grasso, PhD,
Natalie Purcell, PhD, Kara Zamora, PhD, Christopher Koenig, PhD, Tessa Rife,
Pharm D.
Leadership Support: Rina Shah, MD; Diana Nicoll, MD, PhD; Bonnie Graham,
MBA; Ken McQuaid, MD; Mike Shlipak, MD, MPH; Carl Grunfeld, MD.
QUESTIONS? WANT TO GET INVOLVED?
[email protected] and [email protected]