Treatment of Complex and High Risk Chronic Pain - American ...

Carolyn Buesgens, MA, RN-BC, ANP-BCMinneapolis VAHCS1

Objectives1. Define factors contributing to increasedcomplexity and risk in patients with chronic pain2. Explain the limitation of opioids as unimodaltherapy for chronic pain3. Describe a multimodal rehabilitation approach inaddressing factors of high risk or complexchronic pain2

• Biological components• Psychological components• Social components4

• 41year-old man with chronic low back pain• s/p lumbar epidural spinal injections and lumbar fusion• 2011 EMG: No evidence of peripheral neuropathy of the LE• Past history of Valium overdose and suicide attempts.• Positive family hx substance abuse• Mental health diagnoses: depression, anxiety disorder, opioid and alcoholdependence, mood disorder r/t medical condition.• Poor activity tolerance on Methadone 90 mg daily (limited standing andsitting)• Left his job two years ago• Adjuvant medications: gabapentin, cyclobenzaprine, venlafaxine.• Patient expressed desire to come off Methadone• Non-pharmaceutical approaches: stress management classes, pain copingskills class, depression management skills, ACT classes.• Physical therapy “didn’t work”5

• substance abuse• addiction• medical comorbidities• number of pain complaints• past functional history• psychiatric issues• concomitant rx for sedative-hypnotics and/orhigh dose opioid6

• Recent estimates suggest that pain and depressivedisorder co-occur 30-60% of the time• Anxiety disorders may be present 35% of the timeamong person with chronic pain• Pain and PTSD co-occur; 20-34% of persons withchronic pain meet criteria for PTSD; chronic pain ispresent in 45-87% of persons with PTSD• Pain is present in 37-61% of patients seeking substanceuse disorders treatment.• Pain undermines effective treatment for depression,anxiety disorders, PTSD, and substance use disorders.7

• When disability greatly exceeds what would beexpected on the basis of physical findings alone,• When patients make excessive demands on thehealth care system• When patients persist in seeking medical tests andtreatments that are not indicated• When patients display significant emotionaldistress (e.g. depression or anxiety)• When patients display evidence of addictivebehaviors or continual non-adherence to theprescribed treatment regimen.• Adapted from Turk et al, 20108

• Complex-chronic pain does not respond to our usualtreatments (the “pain patients”)• Syndrome encompasses a wide variety of painful conditions• Pattern of declining function (in spite of progressively moreaggressive, expensive, and risky medical treatments• Unpleasant interactions.• Dissatisfied customers.• Medication adherence issues• Overwhelmed and overwhelmingIatrogenesis is a significant problem for this population!A. MarianoSeattle VA9

Kirsh,KL, Passik, S; ExpClin Psychopharm, 2008;16(5)10

• Not all patients are good candidates for opioidtherapy• Risk stratification is helpful in directing acourse of treatment• Low-risk• Intermediate-risk• High-risk11

• Opioid Risk Tool (ORT)• Screener and Opioid Assessment for Patientswith Pain (SOAPP)• Drug Abuse Screening Test (DAST)• CAGE-AID• STARS/SISAP• Current Opioid Misuse Measure (COMM)12

Opioids are such a big part of the problem,principally, because they are such a small partof the solution.”Anthony Mariano, PhDSeattle VAMC13

• High dose opioid use occurred in 2.4% of all chronic pain patients and in8.2% of all chronic pain patients prescribed opioids long-term.• The average dose in high-dose group was 324.9 (SD=285.1)• The only significant demographic difference among groups was race w/black veterans less likely to receive high doses.• High-dose patients were more likely to have four or more pain diagnosesand the highest rates of medical, psychiatric, and substance use disorders.• After controlling for demographic factors and VA facility, neuropathylow back pain, and nicotine dependence diagnoses were associated w/increased likelihood of high-dose prescriptions.• High dose patients frequently did not receive care consistent w/treatment guidelines; There was frequent use of short-acting opioids,urine drug screens were administered to only 25.7% of patients in theprior year, and 32.% received concurrent benzodiazepine rx, which mayincrease risk for OD and death Morasco et al, 201014

Veterans with mental health diagnoses prescribedopioids, especially those with PTSD< weremore likely to have comorbid drug and alcoholuse disorders; receive higher-dose opioidregimens; continue taking opioids longer;receive concurrent prescriptions for opioids,sedative hypnotics, or both; and obtain earlyopioid refills.Seal et al, 201215

2012: A memorandum authored by the chief ofstaff launched the Opioid Safety Initiative limitingtotal daily opioid dose to < 200 MED16

• Bohnert et al. Association between opioidprescribing patterns and opioid overdoserelateddeaths. 2011. JAMA; 305: 1315-1321.• Dunn et al. Opioid prescriptions for chronicpain and overdose. 2010. Annals of InternalMedicine; 152: 85-92.• Gomes et al. Opioid dose and drug-relatedmortality in patients with nonmalignant pain.2010. Arch Int Med; 171;686-69317

2012o Primary Care Team training and educationo Pharmacists and clinical psychologists closelyaligned with each clinico A chronic pain consult service was beguno Patient Pain Education Class startedo Medicine Grand Rounds highlightingavailable behavioral pain programso Tracking/performance measures18

Percent Reduction in Number of Patientsat 50+, 100+, 200+, 500+ and 1000+ MEQ/dayMinneapolis VA May 2011 - September 201210%0%-10%-20%-30%-40%-50%-60%-8%-19%-27%-44%-50%>50 MEQ>100 MEQ>200 MEQ>500 MEQ>1000 MEQ

Your patient does not have a right to opioids.They have a right to good care and appropriatetreatment and in some cases, withdrawing orwithholding opioids is ethically mandated.A Mariano, PhDSeattle VAMC20

AssessmentIdentification of needs (and risk factors)Chronic Pain Care PlanAppropriate referralsOngoing EducationIndividualized follow-up/monitoring22

• Validation – much of the struggle withpatients relates to our communication of doubt• Education – the basis of effective long termcare is a shared understanding of chronic pain• Motivation – patients vary in their willingnessto engage in self management• Activation – primary clinical focus is onchanging the way patients relate to painMariano, PhDSeattle VA24

• Shared by patients who are overwhelmed by painand providers who find these peopleoverwhelming:• Belief that objective evidence of disease/injury isrequired for pain to be “real”• View of pain as the only problem, and which needs tobe avoided at all costs• Expectation that urgent pain relief is the major goal oftreatment• Overconfidence in medical solutions• Provider is the “expert” responsible for outcomes• Patient is helpless “victim” of underlying disease/injuryA. MarianoSeattle VA 25

• Optimal treatment paradigm• Comprehensive assessment and individualizedtreatment plan• Offer hope and help patient connect with theirvalued life• End uncertainty26

“Treating a pain patient can be like fixing a car with four flattires. You cannot just inflate one tire and expect a good result.You must work on all four.”Penny Cowan, Executive DirectorAmerican Chronic Pain Association27

• Supportive therapies• Cognitive-behavioral therapy• Re-conceptualizing of pain as problem to be solved• Coping skills training• Behavioral Interventions• Altering pain-related communication• Behavioral activation• Self-regulatory treatments• Biofeedback• Relaxation training (progressive muscle relaxation;autogenic training)• Hypnosis28

Mindfulness based programs• ACT: Acceptance and Commitment TherapyBooks:- Dahl, J.A. & Lundgren, T. (2006). Living beyond yourpain: Using acceptance and commitment therapy toease chronic pain. Oakland, CA: New Harbinger.-Dahl, J.A., Wilson, K.G., Luciano, C., and Hayes, S.C. (2005).Acceptance and commitment therapy for chronic pain. Reno,NV: Context.• Mind-Body Skills-cmbm.org• Mindfulness Based Stress ReductionKabat-Sinn, J. Full Catastrophe Living: Using the Wisdom of Your Bodyand Mind to Face Stress, Pain and Illness.29

Urgent and absolute pain relief, while it is anappropriate goal in acute and cancer pain, is aninappropriate goal in the treatment of chronicpain. It should not be the major focus oftreatment.A. Mariano, PhDSeattle VAMC30

Redefine the problem and the solutionsExpect some pain – but reject disability andsufferingHave a plan for bad daysActivate, Activate, ActivateBuild a health and hopeful lifestyle31

• Missed opportunities to improve health andprevent further morbidity and disability• Address co-morbidities• Sleep apnea• Insomnia• Obesity• DM• Smoking32

“…the inappropriate treatment of pain includesnontreatment, undertreatment, overtreatment, andthe continued use of ineffective treatments.”The Model Policy for the Use of Controlled Substances for the Treatment of PainFederation of State Medical Boards of the United States, Inc.Medical Boards, 200433

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