the pain decade and the public health l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
THE PAIN DECADE AND THE PUBLIC HEALTH PowerPoint Presentation
Download Presentation
THE PAIN DECADE AND THE PUBLIC HEALTH

Loading in 2 Seconds...

play fullscreen
1 / 43

THE PAIN DECADE AND THE PUBLIC HEALTH - PowerPoint PPT Presentation


  • 148 Views
  • Uploaded on

THE PAIN DECADE AND THE PUBLIC HEALTH. Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania School of Medicine Director of Pain Management, Philadelphia VA Medical Center

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'THE PAIN DECADE AND THE PUBLIC HEALTH' - fineen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
the pain decade and the public health

THE PAIN DECADE AND THE PUBLIC HEALTH

Rollin M. Gallagher, MD, MPH

Clinical Professor, Departments of Anesthesiology and Psychiatry

University of Pennsylvania School of Medicine

Director of Pain Management, Philadelphia VA Medical Center

National Pain Management Coordinating Committee, Veteran Affairs Health System

Editor in Chief, Pain Medicine

Board of Directors: American Academy of Pain Medicine and National Pain Foundation

Immediate Past President, American Board of Pain Medicine

the pain decade and the public health2
The Pain Decade and the Public Health
  • History
    • Conceptualization – Lippe, Saper, Ashburn et al, 1999
    • Matriculation – SB 3163
    • Enrollment – October 28, 2000
    • Life span – 2001 - 2010
pain is a more terrible lord of mankind than even death itself

“Pain is a more terrible lord of mankind than even death itself.”

Albert S. Schweitzer, 1931

On the Edge of the Primeval Forest.

New York: Macmillan, 1931:652

pain medicine history
Pain MedicineHistory
  • Epochs
    • Antiquity to 19th Century
      • Pain a symptom treated by purgation
      • Dichotomy of pain – Descartes and Byron
        • Physical pain
        • Mental pain
pain medicine history5
Pain MedicineHistory
  • Epochs
    • Late 19th Century to 1980’s: Age of medical science and technology
      • Spine surgery and back pain disability
      • Psychogenic pain, compensation neurosis and behavioral medicine
      • John Bonica and IASP
      • Gate Theory of Pain (Wall and Melzack)
      • Hospice and the treatment of suffering
pain medicine history6
Pain Medicine History
  • Epochs
    • Late 20th Century to 2007
      • Rise of epidemiology
        • Failed spine surgery syndrome
        • Geographic variation in surgical rates
        • National variation in opioid analgesia
        • The myth of “psychogenic pain” and psychiatric co-morbidity
        • Pain diseases versus chronic pain
        • Multi-factorial bio-psycho-social causation
diagnosis there are many painful diseases and pain diseases
DIAGNOSIS There Are Many Painful Diseases and Pain Diseases

Inflammatory / Immunological Mediation

Nociceptive pain

Caused by activity inneural pathways inresponse to potentiallytissue-damaging stimuli

Neuropathic pain

Initiated or caused by a primary lesion or dysfunction in the nervous system

CANCER PAIN, LBP,

CHRONIC FACIAL PAIN

(mixed pain states)

Peripheralneuropathy

CRPS*

Postoperativepain

SENSITIZATION

Arthritis

Postherpeticneuralgia

Trigeminalneuralgia

Sickle cellcrisis

Mechanicallow back pain

Neuropathic low back pain

Central post-stroke pain

Diabeticneuropathy

Sports/Exerciseinjuries

Phantom tooth pain

*Complex regional pain syndrome.

phenomenological model of pain disease post herpetic neuralgia
Phenomenological Model of Pain Disease: Post Herpetic Neuralgia

Factors reducing risk for PHN:

Early anti-viral treatment, Early amitriptylene, Good pain control.

BPS

OUTCOMES

Chicken

Pox with

Infection,

with invasion

of dorsal

root ganglion

& spinal

nerves in

childhood

“Shingles”

Activation of virus and disease of acute herpes zoster

Exposure to Varicella

Virus

Post-herpetic Neuralgia

Successful Pain Control

*

*

Initial exposure

Risk factors for chronic pain:

Severity and duration of acute rash, Pain severity, Anxiety severity.

Factors enhancing good outcome:

Access to appropriate pain treatment

Access to rehabilitation.

Precipitating

Factors:

Acute illness,

Stress, Age,

Immuno-

Suppression,

Cancer.

Predisposing

Condition

mismanaged chronic pain is often a personal catastrophe and is a huge public health problem
Quality of life

Physical functioning

Ability to perform activities of daily living (ADLs)

Work

Social consequences

Marital/family relations

Intimacy/sexual activity

Social role and friendships

Psychological morbidity

Fear, anger, suffering

Sleep disturbances

Loss of self-esteem

Medical comorbidites & consequences

Accidents

Medication effects

Immune function

Clinical depression

Mismanaged chronic pain is often a personal catastrophe! ….and is a huge public health problem.

Established effects (by research)of chronic pain

  • Societal consequences
  • - Health care costs
  • - Disability
    • - Lost workdays
    • - Business failures
    • - Higher taxes

Pain causes these problems.

These problems reduce the effectiveness of pain treatment.

They must be managed to obtain good treatment outcomes

depression and pain comorbidity
Depression and Pain Comorbidity

Pain, A condition or symptom that

causes or activates depression

Pain

Remission

Recovery

Response

Relapse

Recurrence

Relapse

“Normalcy”

Progression to disorder

Symptoms

Syndrome

Acute

Continuation

Maintenance

Treatment Phases

Gallagher & Verma, Prog Pain Res Man 2004, Adapted from Kupfer DJ. J Clin Psychiatry.; 1991;52(suppl):28-34. Dohrenwend BP, et al. Pain. 1999;83(2):183-192. Raphael et al Pain 2004

pain medicine history11
Pain MedicineHistory
  • Epochs
    • Late 20th Century to 2007
      • Rise of Neuroscience and Biotechnology
        • Gate theory
        • Molecular biology and neurotransmitters
        • Psychopharmacology
        • Neuropharmacology
        • Neuromodulation
        • disease
pain in our wounded warriors 2002 2007
Pain in our wounded warriors(2002-2007)
  • 686,306 OIF-OEF veterans
  • 229,015 using VA services (33.4%)
      • 43 % have musculoskeletal diseases

(all cause pain by definition)

- back pain most common

      • 37% have mental health disorders

Kang et al. Paper presented at War-Related Illness and Injury Study Center, 2007.

the polytrauma challenge
The Polytrauma Challenge
  • 65% of OEF/OIF combat injuries are caused by improvised explosive devices (IEDs), landmines, shrapnel, and other blast phenomena.
    • multiple visible injuries (tissue wounds)
    • hidden injuries [bone and soft tissue damage, including nerves]
    • 60% with symptoms of traumatic brain injury (TBI) : hearing, vision, cognition, emotional control
    • Over 95% have chronic pain
slide14

Neuro-

plasticity

Ectopic

discharge

Central sensitization

Ectopic

discharge

Alteration

of modulatory

systems

Phenotypical

Changes

ANS activation <<< Stress <<< Pain<<< BRAIN PROCESSING

Spinal cord

Damage

Nerve

injury

+++

C fiber

Abeta fiber

Limb

trauma

Adapted from Woolf & Mannion, Lancet 1999

Attal & Bouhassira, Acta Neurol Scand 1999

slide15

Does early intervention make a difference?

Castillo et al. Pain 124 (2006): 321-329

  • 567 severe single extremity trauma patients at 7 years
  • Predictors of poor outcome before injury include:
    • Alcohol abuse 1 month before injury
    • Older age, lower education, low self efficacy (Gallagher Pain1989)
  • Predictors of poor outcome at 3 months post-injury:
    • Acute pain intensity, anxiety, depression and sleep disturbance
opioid protective effect
Opioid protective effect
  • Patients treated with opioids for pain at three months post-discharge were protected against chronic pain..
  • despite the fact that these patients had higher pain intensity levels and were thus at higher risk for chronic pain
  • lending support to the theory that…

..early aggressive pain treatment may protect patients from central sensitization and chronic pain.”

early continuous and restorative pain management in injured soldiers the challenge ahead
Early, Continuous, and Restorative Pain Management in Injured Soldiers: The Challenge Ahead

Rollin M. Gallagher, MD, MPH

Rosemary Polomano, PhD, RN

Pain Medicine 2006;7(4):284-286

John Farrar, MD, PhD

David Oslin, MD

Wensheng Guo, PhD

Chester Buckenmaier, MD

Geselle McKnight, CRNP

Alexander Stojadinovic, MD

the end cprs pain cycle
THE END: CPRS Pain Cycle
  • Pathology:
  • Muscle atrophy,
  • weakness;
  • Bone
  • demineralization;
  • -Depression
  • Pathophysiology of Maintenance:
  • Radiculopathy
  • Neuroma traction
  • Myofascial sensitization
  • Brain pathology (loss, reorganization)
  • Psychopathology
  • of maintenance:
  • Encoded anxiety
  • dysregulation
  • - PTSD
  • -Emotional
  • allodynia
  • -Mood disorder

Central

sensitization

Acute injury

and pain

Disability

Less active

Kinesophobia

Decreased

motivation

Increased

isolation

Role loss

Peripheral

Sensitization:

Na+ channels

Lower threshold

Neurogenic

Inflammation:

- Glial activation

- Pro-inflammatory

cytokines

- blood-nerve barrier

dysruption

mechanism targets for neuropathic pain pharmacotherapy
Mechanism Targets For Neuropathic Pain Pharmacotherapy

(Adapted from Beydoun 2001)

BRAIN

Modulation by

Norepinephrine

Serotonin

Endogenous opiates

Tricyclics, SSRIs,

SNRIs (Venlafaxine,

Duloxetine),

Tramadol, Opiates

Voltage gated Ca channels

(L & PQ presynaptic):

Gabapentin, Pregabalin

Anti-inflammatory

NSAID, Cox 2

Spinal

cord

NMDA antagonists:

Ketamine, Dextromethorphan

PNS

NA channels Lidocaine Patch 5%

CarbamazepineOxycarbazine

Tricyclics

Topiramate

2 agonists

Tizanidine

Clonidine

pain medicine history21
Pain MedicineHistory
  • Epochs
    • Late 20th Century to 2007
      • Emergence of the specialty of Pain Medicine
      • Evolving organizational models of care
        • Sequential care model
        • Multidisciplinary pain center model
        • Managed care model
        • Pain medicine and primary care community rehabilitation model
the tertiary sequential care model
The tertiary, sequential care model

1

1

INJURY/SYMPTOM

Emergency

Services

TIME

1

Primary

Care

2

2

(5)

4

Specialty Office #1

(6)

3

TREATMENT

FAILURES

Specialty Office #2

3

4

ALTERNATIVE TREATMENTS

Specialty Office #3

3

5

CHASING THE SYMPTOM THROUGH A REDUCTIONISTIC, BIOMEDICAL MODEL

Specialty Office #4

4

Gallagher RM. MedClin N Am 83(5): 555-585, 1999.

the multi disciplinary biobehavioral pain center model
The multi-disciplinary, biobehavioralpain center model

INJURY/SYMPTOM

time

1

Emergency

Services

1

Primary

Care

1

5

3

Specialty Offices, Alternative Care

Treatment

Failure

Treatment

Success

2

2

Multidisciplinary

Pain Center: MD, PT, OT,

Behav Med, Voc Rehab

4

the managed primary care model
The managed primary care model

DOES NOT WORK FOR PATIENTS OR POPULATIONS

time

INJURY/SYMPTOM

Emergency

Services

Primary

Care

Office

1

1

(4)

3

2

JUST SAY NO!!

Specialty

Offices

Treatment

Failures

(3)

6

2

5

INSURANCE

LOSS

JOB LOSS

Gallagher RM. MedClin N Am 83(5): 555-585, 1999.

slide25

Cost vs. Quality

(From W. Brose, MD)

Resource

Excess care

Best practice

Quality of care (outcomes)

the pain medicine and primary care community rehabilitation model
The pain medicine and primary care community rehabilitation model

A “systems” model for pain management that is based on three core principles:

1) empowerment by education of and support for

primary care provider, patient and community

2) outcomes focus: evidence based, quality

improvement approach

3) shared responsibility for outcomes amongst,

patient, providers, health care system, and payers

4) Easy access for early intervention

5) Evidence-based rational polypharmacy imbedded

in goal-oriented, stepped, selectively multi-modal treatment (e.g., PT, behavioral, social) **

** Gallagher RM. Rational polypharmacy in integrated pain treatment. Am J Phys Med & Reh 2005(S);84(3):S64-76

pain medicine and primary care community rehabilitation model
Pain medicine and primary care community rehabilitation model

INJURY/SYMPTOM

Multidisc-

iplinary

Pain

Center

7

1

Emergency

Services

PrimaryCare: ClinicalAlgorithms

Community

Support &

Services (PT, OT, Voc,

behavioral, pharmacy)

2

Sub-specialty

Eval. & mgmt.

Recurrent

or persistent

pain impairing

function

(4)

3

5

Integrated

Pain Medicine

Eval & Services:

Med. trials, PT, Blocks, Behavioral mgmt.

6

3

Treatment

Failure

6

Gallagher RM. MedClin N Am 83(5): 555-585, 1999.

.

algorithm for medication selection in chronic pain with and without comorbid depression
Algorithm for Medication Selection in Chronic Pain With and Without Comorbid Depression

Neuropathicpain

Nociceptivepain

Pain condition +depression

Secondary depression

Primary D.

Secondary sleepdisturbance

Evaluate risks

Persists afteradequateanalgesia

Evaluate risks

Persists afteradequateanalgesia

NSAIDs,Cox-IIs,opioids, lidocaine p.? doxepin cr.?

SSRI trial

Evaluate risks

Evaluate risks

Lidocaine patch;gabapentin & other AED (Ca+ & Na+ channels); alpha 2 agonists (tizanidine, clonidine);opioids

SNRIs: venlafaxine, duloxetine

Antihistamine,zolpidem,etc.

Trazodone

Low-doseTCA

Titrate TCAs (Na+ channels and SNRI) : desipramine, nortriptyline,

Adapted from Gallagher RM, Verma S. Semin Clin Neurosurgery. 2004.

This information concerns uses that have not been approved by the US FDA.

slide29

The Opioid Renewal Clinic: A structured approach to managing opioids for pain in primary care Wiedemer N, et al Pain Medicine 2007Bair M, Pain Medicine 2007Aberrant Behavior Categories over one year

our conundrum
OUR CONUNDRUM

Growing societal awareness of:

1. the prevalence of inadequately treated chronic pain

2. its impact on society

3. the need for access to effective pain treatment

vs

Growing societal awareness of:

1. The rapidly increasing rate of use of opioid prescriptions

2. The increasing rate of prescription drug abuse

3. The increasing rate of prescription drug abuse deaths

balanced pain policy initiative center for practical bioethics kansas city mo
Balanced Pain Policy InitiativeCenter for Practical BioethicsKansas City, MO
  • American Academy of Pain Medicine
  • American Pain Society
  • American Society of Addiction Medicine
  • DEA
  • FSMB
  • National Association of Attorneys General
  • Wisconsin Pain Policy Center
  • Wisconsin Department of Regulation & Licensing
physicians charged with opioid analgesic prescribing offenses
Physicians Charged with Opioid Analgesic Prescribing Offenses

Goldenbaum, Donald M., Ph.D.; Christopher, Myra; Gallagher, Rollin M., M.D., M.P.H.; Fishman, Scott, M.D; Payne, Richard, M.D.; Joranson, David, MSSW;

Edmondson, Drew, J.D.; McKee, Judith, J.D.; Thexton, Arthur, J.D., M.A.

Author Affiliations:

  • Center for Practical Bioethics (Goldenbaum and Christopher)
  • AAPM: Philadelphia V.A. Medical Center/University of Pennsylvania (Gallagher)
  • AAPM: U. California, Davis (Fishman)
  • Duke University Divinity School (Payne)
  • U. Wisconsin (Joranson)
  • Attorney General, State of Oklahoma (Edmondson)
  • National Association of Attorneys General (McKee)
  • Wisconsin Department of Regulation & Licensing (Thexton).
principles of treatment summary
PRINCIPLES OF TREATMENT:Summary

Primary prevention:

  • avoid injuries and diseases

Secondary prevention:

  • When injuries or diseases occur, prevent or minimize nociception or neural activation of pain pathways, improve coping and adaptation, and restore and maintain function
  • Risk management

Tertiary prevention

  • manage perpetuating factors, control pain and restore function and quality of life
decade of pain control and research
Decade of Pain Control and Research
  • Goals: To Promote Pain Medicine
    • Research
    • Education
    • Clinical Practice
    • Advocacy & Policy Development
  • How are we doing after 6 years?
  • A snapshot
slide35
Growth in the Number of Published Articles on Pain over the Past 30 years. (Source: June 10, 2003, Pub Med search with keyword pain)

Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004

slide36

Growth in the Number of Published Articles on Nociception over the Past 30 years. (Source: June 10, 2003, Plumbed search with keyword nociception)

Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004

slide37

Growth in the Number of Published Articles related to pain over the past 3.5 years.(Source: August 2, 2004, Plumbed search with keywords: pain, neuropathic, nociception)

No. Published Articles

-------------------------------------------

Search 1995-99 2000-04

Term (5 years) (3.5 years) % increase

Pain 59,749 72,018 > 21%Neuropathic 1,527 2,481 > 62%Nociception 831 1,220 > 47%

journal proliferation
Journal proliferation
  • Concomitantly rapid rise in numbers of journals devoted to pain
    • 2 new academic journals started in 2000 indexed recently by the National Library of Medicine for MEDLINE, Index Medicus and Pub Med.

- Pain Medicine indexed 2003; Imp F. 2.477

Increased to six issues yearly in 2005

Increased to eight issues in 2007

Increase to twelve issues in 2009

- Journal of Pain indexed in 2004

    • Neuromodulation, likely to follow.
    • Growth of review pain journals (Pain Practice, Pain Physician, J Opioid)
    • Multiple special supplements to other specialty society journals (Family Practice, Neurology, Psychiatry, JAMA, Internal Medicine, Neurosurgery)
    • Multiple sponsored articles and “throw away” journals
nih research initiatives
NIH Research Initiatives
  • Pain is much more prominent in RFAs from several institutes.

Challenge:

Capps-Rogers 2007: HR 2994

“The National Pain Care Policy Act 2007”

  • National Cancer Institute:

Challenge:

Will pain and palliative care become a pre-requisite in evaluating CA clinical trials?

va military initiatives
VA-military Initiatives

Senator Akaka (D-HI) introduces bill to enhance VA and military pain care and research

  • Promoting Improvements in Treatment of Veterans Suffering from Chronic and Acute Pain
  • Provide research funding for studies of pain in military and in VA
  • October 15, 2007
slide41

Transition to Community Care:

MILITARY HOSPITAL, USA

MILITARY BASE CLINIC, USA

Pain Medicine and Mental Health Services

COMMUNITY HEALTH SYSTEM

VETERANS HEALTH SYSTEM

COMMUNITY SUPPORT SYSTEM

societal interest
SOCIETAL INTEREST
  • Non-profit advocacy organizations:
    • American Chronic Pain Association
    • National Pain Foundation:
      • www.nationalpainfoundation.org
    • American Pain Foundation:
      • www.painfoundation.org
the future
The future?
  • Pain Medicine as a Specialty
    • Standardize training
    • Create qualified teachers of all doctors
      • Medical schools
      • Residencies
      • Pain Fellowships
    • Promote important research
  • Societal Awareness for Advocacy and Policy Change
  • Organization of health care
    • Performance-based medicine
    • Pain Medicine and Primary Care Community Rehabilitation Model
    • Integrated medical record
    • Risk management