Chronic Pain Syndrome and interdisciplinary evidence-based treatment

1. Chronic Pain Syndrome and interdisciplinary evidence-based treatment Nicolle C. Angeli, PhD Clinical Psychologist Chronic Pain Rehabilitation Program James A. Haley VA Hospital

2. 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.

3. 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.

4. The Process of Pain: From Acute to Chronic Low Back Pain • 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%. Chronic Chronic Chronic 3-4 months 3-4 months 3-4 Months 2 weeks 2 weeks 2 weeks 1 month 1 month

5. From Chronic Pain to Chronic Pain Syndrome Of the 10% with chronic pain • 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. Chronic Pain Syndrome Chronic Pain

6. Transition to Chronic Pain Syndrome • Unrelatedto 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).

7. 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/ compensation

8. Chronic Pain SyndromeSymptoms • 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

9. Role of the Chronic Pain Cyclein Chronic Pain Syndrome • Reducing activity to minimize pain may help in the short term but leads to deconditioning over time and increased pain • Psychological, behavioral, and interpersonal problems develop or worsen as a result of inactivity/physical deconditioning Physical Deconditioning Pain Psychosocial Distress

10. 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)

11. 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).

12. 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”

13. Opioids and Sleep • Research indicates that opioids have negative impact on sleep time, efficiency, & REM (Dimsdaleet 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)

14. 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)

15. 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

16. Opioids and Negative Affect • Further complicated by creation of cycle of opioid-induced 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 Physical Deconditioning Pain Psychosocial Distress

17. 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

18. 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 involves medical approaches.

19. 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.”

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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 Physical Deconditioning Pain Psychosocial Distress

32. Cognitive behavioral therapy for chronic pain : Key Components • Identify, challenge, correct cognitive distortions • “This pain is killing me. It’s ruining my life. Nothing helps and no one understands.” • Learn, implement, practice relaxation techniques • Diaphragmatic breathing, PMR, visualization • Monitor physical activities, develop pacing • Time-based pacing • Identify, increase pleasurable activities • Recreation, hobbies, social activities • Anticipate obstacles for successful implementation • Problem-solve

33. 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

34. PAIN TEAM MEMBERS Psychology Physical Therapy Occupational Therapy Pool Therapy Social Work Chronic Pain Pharmacy Psychiatry Dietetics Vocational Rehabilitation Recreation Therapy Nursing Medicine

35. 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

37. 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

38. Results • Both groups improved significantly from admission to discharge on ALL measures. Improvements in: • Pain severity; ADLs; mobility; negative affect; vitality; pain-related 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.

39. 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

40. Inpatient Chronic Pain Rehabilitation Program FY13 Outcomes:10/01/2012-09/30/2013

41. Improvement in functioning at discharge

42. Percentage of functional improvement

43. Follow-up Data

44. Improvement in functioning at Follow-Up

45. Percentage of functional improvement at Follow-Up

46. KEYS TO PROGRAM SUCCESS • Team functioning • Designated personnel who are committed • Close, constant communication • Consistent message • Administrative support

47. Questions?