Chronic Pain ManagementChronic Pain ManagementWhat is it?What is it?

What can be done?What can be done?What is Functional Restoration?What is Functional Restoration?

IS Return to Work possible?IS Return to Work possible?

Steven Feinberg, M.D.Steven Feinberg, M.D.John Massey, M.D.John Massey, M.D.

Bay Area Pain & Wellness CenterBay Area Pain & Wellness CenterFunctional Restoration ProgramFunctional Restoration Program

Los Gatos, CaliforniaLos Gatos, California

IntroductionIntroduction

The Pain PuzzleThe Pain Puzzle

Pain is a complex clinical phenomenonPain is a complex clinical phenomenon

Pain is a symptom when it occurs acutely Pain is a symptom when it occurs acutely but a disease when it presents chronicallybut a disease when it presents chronically

Exam time consuming and physically and Exam time consuming and physically and psychologically taxing to physician and psychologically taxing to physician and patientpatient

Cost of Chronic PainCost of Chronic Pain

Billions yearly in health care costs and Billions yearly in health care costs and lost work productivitylost work productivityConsiderable human sufferingConsiderable human suffering– IndividualIndividual– Significant othersSignificant others

Society losesSociety loses– Loss of a productive member of societyLoss of a productive member of society

What is Chronic Pain?What is Chronic Pain?

Chronic pain is persistent or recurrent Chronic pain is persistent or recurrent pain, lasting beyond the usual course of pain, lasting beyond the usual course of acute illness or injury, or more than 3 - 6 acute illness or injury, or more than 3 - 6 months, and adversely affecting the months, and adversely affecting the patient’s well-beingpatient’s well-being

Pain that continues when it should notPain that continues when it should not

What is Acute Pain?What is Acute Pain?

Physiologic response to tissue damagePhysiologic response to tissue damage

Warning signals damage/dangerWarning signals damage/danger

Helps locate problem sourceHelps locate problem source

Has biologic value as a symptomHas biologic value as a symptom

Responds to traditional medical modelResponds to traditional medical model

Life temporarily disrupted (self limiting)Life temporarily disrupted (self limiting)

What is Chronic Pain?What is Chronic Pain?

Difficult to diagnose & perplexing to treatDifficult to diagnose & perplexing to treat

Subjective personal experienceSubjective personal experience

Cannot be measured except by behaviorCannot be measured except by behavior

May originate from a physical source but May originate from a physical source but slowly it “out-shouts” and becomes the slowly it “out-shouts” and becomes the diseasedisease

It has no biologic value as a symptomIt has no biologic value as a symptom

Life permanently disrupted (relentless)Life permanently disrupted (relentless)

Pain ClassificationPain Classification

Classification by MechanismClassification by Mechanism– Nociceptive: a normal physiologic response to Nociceptive: a normal physiologic response to

potential or actual tissue damagepotential or actual tissue damage– Neuropathic: a pathophysiologic pain state Neuropathic: a pathophysiologic pain state

associated with inflammation or peripheral associated with inflammation or peripheral nerve injurynerve injury

– Central: a pathophysiologic pain state Central: a pathophysiologic pain state produced by lesions of the central nervous produced by lesions of the central nervous system that occur in the spinal cord, system that occur in the spinal cord, brainstem or brainbrainstem or brain

The Scope & Treatment of PainThe Scope & Treatment of Pain

Chronic pain is never unidimensionalChronic pain is never unidimensional

It is never purely biological or solely It is never purely biological or solely psychologicalpsychological

The treatment of pain is still in the "gray" The treatment of pain is still in the "gray" area of medical practicearea of medical practice

It is approached differently depending on It is approached differently depending on the education, training, experience and the education, training, experience and bias of the physicianbias of the physician

Getting to Chronic PainGetting to Chronic Pain

Why and how do some people become Why and how do some people become dysfunctional chronic pain patients?dysfunctional chronic pain patients?How does a person with a problem become How does a person with a problem become a patient with an illness? a patient with an illness? Nortin Hadler, M.DNortin Hadler, M.D

The responsibility for this disastrous The responsibility for this disastrous situation rests with the healthcare system, situation rests with the healthcare system, the medical community and the patient and the medical community and the patient and their significant otherstheir significant others

Chronic Pain is DevastatingChronic Pain is Devastating

Robs the individual of his or her ability to Robs the individual of his or her ability to have a productive, meaningful and have a productive, meaningful and enjoyable lifeenjoyable life

It takes away hobbies, recreation, friends, It takes away hobbies, recreation, friends, and the ability for the person to provide and the ability for the person to provide financial support to his or her family financial support to his or her family through gainful employmentthrough gainful employment

The individual is not comfortable while The individual is not comfortable while awake, and usually sleeps poorly at nightawake, and usually sleeps poorly at night

Chronic Pain CharacteristicsChronic Pain Characteristics

Weight gain and sexual difficulties occurWeight gain and sexual difficulties occur

Anger, depression, despair and irritability Anger, depression, despair and irritability are commonare common

Chronic pain is often accompanied by loss Chronic pain is often accompanied by loss of hope and self-esteemof hope and self-esteem

It saps the individual’s energy and the It saps the individual’s energy and the ability to think straightability to think straight

Chronic Pain CharacteristicsChronic Pain Characteristics

Pain behavior Pain behavior (braces, canes, posturing, etc.)(braces, canes, posturing, etc.)

Significant lifestyle alterations and lossesSignificant lifestyle alterations and losses

Drug overuse, misuse & dependencyDrug overuse, misuse & dependency

Multiple medical and surgical failuresMultiple medical and surgical failures

Not improving with traditional careNot improving with traditional care

Treatment is often fraught with side-effectsTreatment is often fraught with side-effects– Cognitive, Behavioral, & MedicalCognitive, Behavioral, & Medical

Chronic Pain CharacteristicsChronic Pain Characteristics

Inactivity & excessive down timeInactivity & excessive down time

Somatic preoccupationSomatic preoccupation

Continued medical cure seekingContinued medical cure seeking

Subjectives outweigh objectivesSubjectives outweigh objectives

Physical deconditioning & low energyPhysical deconditioning & low energyPerceived disability & inability to workPerceived disability & inability to work

Chronic Pain Medical CareChronic Pain Medical Care

Providing quality chronic pain medical care Providing quality chronic pain medical care is often more "art" than "science“is often more "art" than "science“

The H&P is of critical importance The H&P is of critical importance

It is important to get a sense of the depth It is important to get a sense of the depth and breadth of the person’s life experiences and breadth of the person’s life experiences and current social situationand current social situation

What are the individual’s beliefs about the What are the individual’s beliefs about the cause, meaning, impact, expectation, cause, meaning, impact, expectation, perceptions and goals regarding the painperceptions and goals regarding the pain

Chronic Pain Medical CareChronic Pain Medical Care

Recognize problem cases or "Red Flags“Recognize problem cases or "Red Flags“Determine motivating factors and what the Determine motivating factors and what the patient needs and wants?patient needs and wants?Recognize the difference between organic Recognize the difference between organic and non-organic disability factorsand non-organic disability factorsIt is important to recognize the rare It is important to recognize the rare malingerer who is perpetrating a fraud from malingerer who is perpetrating a fraud from the legitimate patient who magnifies or the legitimate patient who magnifies or exaggerates symptoms unconsciously to exaggerates symptoms unconsciously to gain attention and supportgain attention and support

Chronic Pain TreatmentChronic Pain Treatment

Difficult for health care professionalsDifficult for health care professionals

Chronic pain management not taughtChronic pain management not taught

Conventional medical education does not Conventional medical education does not teach us how to deal with chronic painteach us how to deal with chronic pain

The education MDs receive actually teaches The education MDs receive actually teaches how to mismanage chronic pain problemhow to mismanage chronic pain problem

Patients are demanding & difficultPatients are demanding & difficult

Payers suspicious of chronic pain treatmentPayers suspicious of chronic pain treatment

Utilization Review is problematicUtilization Review is problematic

CP Internal Risk Factors ICP Internal Risk Factors I

The individual's past pain experiencesThe individual's past pain experiencesCultural issuesCultural issues

Subjective pain intensitySubjective pain intensity– individuals who experience high levels of individuals who experience high levels of

subjective pain intensity during the acute phase subjective pain intensity during the acute phase appear to have a significantly increased risk for appear to have a significantly increased risk for developing chronic disabling paindeveloping chronic disabling pain

Secondary gain/rewards for illness behaviorSecondary gain/rewards for illness behavior

CP Internal Risk Factors IICP Internal Risk Factors II

Premorbid psychological make-up:Premorbid psychological make-up:– DepressionDepression– MMPI FindingsMMPI Findings– Axis II Personality DisordersAxis II Personality Disorders

History of dysfunctional childhoodHistory of dysfunctional childhood– EmotionalEmotional– PhysicalPhysical– Sexual abuseSexual abuse– Dysfunctional or distant parentsDysfunctional or distant parents

CP Internal Risk Factors IIICP Internal Risk Factors III

Substance abuse (alcohol, tobacco, drugs)Substance abuse (alcohol, tobacco, drugs)Marital and/or family problemsMarital and/or family problemsJob dissatisfactionJob dissatisfactionUnemploymentUnemployment– The degree of risk for developing chronic pain is The degree of risk for developing chronic pain is

influenced by the existing job market, the climate influenced by the existing job market, the climate for rehiring and the patient's transferable skillsfor rehiring and the patient's transferable skills

CP Internal Risk Factors IVCP Internal Risk Factors IV

The low activity/high pain behavior factorThe low activity/high pain behavior factor– sedentary lifestyles and/or exhibit significant overt sedentary lifestyles and/or exhibit significant overt

pain behaviors and demonstrating extreme reactions pain behaviors and demonstrating extreme reactions during physical examinationduring physical examination

Negative beliefs/fear about pain manifests when Negative beliefs/fear about pain manifests when patients express strong beliefs or fears that their patients express strong beliefs or fears that their pain is harmful, disabling, or out of their control, pain is harmful, disabling, or out of their control, or that increasing their activity level would or that increasing their activity level would increase their painincrease their pain

Chronic Pain External FactorsChronic Pain External Factors

Physicians & significant others often support Physicians & significant others often support pain complaints and behaviorpain complaints and behavior

Continued tests and medications for Continued tests and medications for increasing complaints support the person’s increasing complaints support the person’s perception of being dysfunctionalperception of being dysfunctional

Illness behavior rewarded by attention from Illness behavior rewarded by attention from others and time out from unpleasant tasksothers and time out from unpleasant tasks

Incentives & rewards (financial, time off, etc) Incentives & rewards (financial, time off, etc) for illness behaviorfor illness behavior

Treatment Goals - ITreatment Goals - I

Reduce and manage painReduce and manage pain– Decreased subjective pain reportsDecreased subjective pain reports– Decreased objective evidence of disease Decreased objective evidence of disease

Optimize medication useOptimize medication use

Increase function & productivityIncrease function & productivity

Restore life activitiesRestore life activities

Increase psychological wellnessIncrease psychological wellness

Reduce level of disabilityReduce level of disability

Treatment Goals - IITreatment Goals - II

Stop cure seekingStop cure seeking

Reduce unnecessary health careReduce unnecessary health care

Prevent iatrogenic complicationsPrevent iatrogenic complications

Improve self-sufficiencyImprove self-sufficiency

Achieve medical stabilizationAchieve medical stabilization

Prevent relapse / recidivismPrevent relapse / recidivismMinimize costs - maintain qualityMinimize costs - maintain qualityReturn to gainful employmentReturn to gainful employment

Effective CPP Evaluation & RxEffective CPP Evaluation & Rx

It is more important to know about the patient who has the disease than about the disease the patient has Sir William Osler

Readiness to Change concept– Ready to change

– Yes But…

– No way…

There is a fine line for the treating physician between reasonable caring and concern vs. enabling illness and adding to the patient’s sense of entitlement and disability

Effective CPP Evaluation & RxEffective CPP Evaluation & Rx

Just as it is important to know how to Just as it is important to know how to treat, it is also important to know when to treat, it is also important to know when to stop - some patients can’t be “fixed”stop - some patients can’t be “fixed”

Limit exposure to invasive interventionsLimit exposure to invasive interventions

Start by doing simple things firstStart by doing simple things first– Listening, understanding and educatingListening, understanding and educating– When reasonable, progress to appropriate When reasonable, progress to appropriate

& increasingly invasive treatments, & increasingly invasive treatments, medications & proceduresmedications & procedures

Chronic Pain EvaluationsChronic Pain Evaluations

comprehensive multidisciplinary comprehensive multidisciplinary evaluations offers a means of developing evaluations offers a means of developing an appropriate treatment planan appropriate treatment plan

This can help identify factors which may This can help identify factors which may prolong complaints of pain and disability prolong complaints of pain and disability despite traditional medical caredespite traditional medical care

Such an evaluation can also identify who Such an evaluation can also identify who would benefit from a more structured and would benefit from a more structured and intensive functional restoration programintensive functional restoration program

Treatment ApproachesTreatment Approaches

MedicationsMedications– Non-opioid analgesics (acetaminophen & Non-opioid analgesics (acetaminophen &

NSAIDs)NSAIDs)– OpioidsOpioids– AntidepressantsAntidepressants– Neuroleptics / PsychotropicsNeuroleptics / Psychotropics– AnticonvulsantsAnticonvulsants– Membrane stabilizersMembrane stabilizers– Muscle RelaxantsMuscle Relaxants– Systemic Local AnestheticsSystemic Local Anesthetics– NMDA-receptor AntagonistsNMDA-receptor Antagonists

Medication ManagementMedication Management

Medication use should be individualized Medication use should be individualized and determined byand determined by– benefitbenefit– costcost– potential side effectspotential side effects– other medical problemsother medical problems

Partial rather than full relief of pain, sleep Partial rather than full relief of pain, sleep loss, or other symptoms is often a more loss, or other symptoms is often a more realistic goal with using medicationsrealistic goal with using medications

Analgesics for Chronic Pain - IAnalgesics for Chronic Pain - I

Analgesic and other drugs are the most Analgesic and other drugs are the most common method of chronic pain treatmentcommon method of chronic pain treatment

Pain medications can be a blessing for Pain medications can be a blessing for some patients in chronic pain, but they are some patients in chronic pain, but they are not universally effectivenot universally effective

Analgesics are generally effective for tissue Analgesics are generally effective for tissue injury (nociceptive pain) but less effective for injury (nociceptive pain) but less effective for pain resulting from damage to nervous pain resulting from damage to nervous system (neuropathic pain)system (neuropathic pain)

Analgesics for Chronic PainAnalgesics for Chronic Pain

Short-term use of analgesics is rarely Short-term use of analgesics is rarely worrisome, but prolonged use increases worrisome, but prolonged use increases the possibility of adverse reactions the possibility of adverse reactions including daytime sleepiness, internal including daytime sleepiness, internal organ problems, poor coordination and organ problems, poor coordination and balance (possibly leading to falls), balance (possibly leading to falls), cognitive dysfunction with memory and cognitive dysfunction with memory and concentration difficulties, behavioral concentration difficulties, behavioral changes and addictionchanges and addiction

OpioidsOpioids

A select group of pain patients benefits A select group of pain patients benefits from opioids, with resultant pain reduction from opioids, with resultant pain reduction and improved physical and psychological and improved physical and psychological functioningfunctioning

They have minimal side effects & show They have minimal side effects & show increased activity levels & less painincreased activity levels & less pain

Other patients do poorly with opioids, Other patients do poorly with opioids, experiencing tolerance and side effects, experiencing tolerance and side effects, especially with escalating dosesespecially with escalating doses

Measuring Opioid UsefulnessMeasuring Opioid Usefulness

Each individual with chronic pain should be Each individual with chronic pain should be viewed as unique and the ultimate outcome viewed as unique and the ultimate outcome of the use of opioid medication must be of the use of opioid medication must be viewed in terms ofviewed in terms of– Pain reliefPain relief– Objective gains (function or increased activity)Objective gains (function or increased activity)– Does taking an opioid allow the person to be Does taking an opioid allow the person to be

happier and do more things without happier and do more things without unacceptable side effects or do the medications unacceptable side effects or do the medications only create more problems and no observable only create more problems and no observable change in activity level?change in activity level?

Adjunctive Treatment ModalitiesAdjunctive Treatment Modalities

Joint, bursal & trigger point injectionsJoint, bursal & trigger point injectionsBotulinum toxin injectionsBotulinum toxin injectionsNerve root and sympathetic blocksNerve root and sympathetic blocksPeripheral and plexus blocksPeripheral and plexus blocksFacet and medial branch injectionsFacet and medial branch injectionsLidocaine infusionsLidocaine infusionsEpiduralsEpiduralsNeuroablative techniquesNeuroablative techniques– Chemical, Thermal, & SurgicalChemical, Thermal, & Surgical

NeuromodulationNeuromodulation– Spinal cord stimulators & Implanted spinal pumpsSpinal cord stimulators & Implanted spinal pumps

Physical & Occupational TherapyPhysical & Occupational Therapy

ActiveActive– Improved body mechanicsImproved body mechanics– Spine stabilizationSpine stabilization– Stretching & strengtheningStretching & strengthening– Aerobic conditioningAerobic conditioning– Aquatics therapyAquatics therapy– Work hardeningWork hardening– Self-directed fitness programSelf-directed fitness program

Psychological ApproachesPsychological Approaches

Non-drug pain management skillsNon-drug pain management skills– Anxiety & depression reductionAnxiety & depression reduction– Biofeedback, relaxation training, stress reduction Biofeedback, relaxation training, stress reduction

skills, mindfulness meditation, & hypnosisskills, mindfulness meditation, & hypnosis– Cognitive restructuringCognitive restructuring

Improve coping skillsImprove coping skills

Learn activity pacingLearn activity pacing

Habit reversal Habit reversal

Maintenance and relapse preventionMaintenance and relapse prevention

Functional RestorationFunctional Restoration

Locus of control issuesLocus of control issuesTimely and accurate diagnosisTimely and accurate diagnosisAssessment of psychosocial strengths and Assessment of psychosocial strengths and weaknesses including analysis of support systemweaknesses including analysis of support systemEvaluation of physical and functional capacityEvaluation of physical and functional capacityTreatment planning and functional goal setting for Treatment planning and functional goal setting for return to life and work activitiesreturn to life and work activitiesActive physical rehabilitationActive physical rehabilitationCognitive behavioral treatmentCognitive behavioral treatmentPatient and family educationPatient and family educationFrequent assessment of compliance and progressFrequent assessment of compliance and progress