Nancy Elder, MD, MSPH Cincinnati, Ohio

Transcription

1 Nancy Elder, MD, MSPH Cincinnati, Ohio

2 My neck has hurt ever since my motorcycle crash in You got to help me, Doc! Great. Another drug seeking patient wanting narcotics.

3 When I was working and had insurance, my headaches were under control with cymbalta, topamax, massage therapy, botox injections and weekly relaxation therapy sessions with my personal trainer. Now I don t have anything and I can t stand the pain! Now I have a headache, too! All we have in our program is tylenol, ibuprofen and a 2 page relaxation handout.

4 Acknowledge that chronic (nonmalignant) pain IS difficult for patients, for families, for friends and for providers Learn how to systematically ASSESS, FOLLOW-UP and MONITOR patients with chronic pain Learn how to systematically ASSIST patients towards self-care and self-management Learn how to increase your comfort dealing with patients with chronic pain Review evidence based guidelines for caring for patients with chronic pain

5 Chronic non-malignant pain (CNMP or CP) is Pain that that persists beyond the usual course of disease or injury Pain that lasts longer than 3 or 6 months Pain that is unrelated to cancer and does not occur at the end of life Health providers frequently describe patients with CP as difficult, problem or heartsink patients vague, difficult to describe, undifferentiated problems interpersonal difficulties, reflected in a perceived abrasive behavioral style they don t get better

6 Good population estimates are remarkably lacking Nationwide, between 11 50% of people will experience chronic pain What we do know: Musculoskeletal pain, especially joint and back pain, is the most common single type of chronic pain. Most people with chronic pain have multiple sites of pain Chronic pain rates are steadily increasing

7 Variable LESS income and education Women Elderly African-Americans Hispanics Amount of pain experienced/reported Receipt of appropriate pain treatment Prevalence of chronic pain among the homeless is unknown, but health disparities and the presence of vulnerable populations among the homeless would suggest a high prevalence.

8 3 Key Take Home Points All pain is subjective Chronic pain is multifactorial Chronic pain requires a biopsychosocialspiritual approach In order to better assess, treat and monitor CP, we need to better understand what makes up CP, and especially how homelessness and chronic pain interact

9 Some of it, we re born with Multiple risk-conferring genes Pain sensitivity / nocioception Pain responses to opioids Likelihood of addiction

10 Our childhood experiences influences our adult pain The cumulative effort needed to adapt to acute stresses can eventually harm body systems ( allostatic load theory) Growing up poor, poorly educated in a stressful environment makes the body more prone to pain and less able to handle it well. Responses to pain are generally learned in childhood.

11 Multiple regions in the brain are involved in pain processing and modulation Brain regions actually undergo physical changes as a result of chronic pain

12 Genetic emotional temperament and background acculturation affect the experience of pain Pain affects emotional temperament and acculturation % of people with chronic pain have a mental disorder, but direction of causality is unclear More pain is associated with negative emotions More depression and anxiety are associated with more reported pain and more use of pain meds Positive emotions are associated with a better response to treatment, less disability, better coping and better quality of life.

13 Beliefs, anticipation and expectation are better predictors of pain and disability than any physical pathology Pain catastrophizing (dwelling on and magnifying pain, feeling helpless) is associated with increased pain and dysfunction and a slower recovery

14 Chronic pain can be a disease in itself Genetic, childhood, brain, emotional, cognitive and physical factors play a role in chronic pain Chronic pain is a health disparities issue, with vulnerable groups receiving less appropriate pain management All pain is personal

15 Assess, assess, assess. Reassess, reassess, reassess Pain perception Functional limitations Emotional impact Other co-morbidities, including existing mental health issues, other medical problems, substance abuse, cognitive difficulties (including traumatic brain injury)

16 HCH Clinician attitudes towards pain management (101 HCH clinician Network members in 2010) Agree *It is difficult to manage pain in patients with a history of addiction. 90(91%) *Pain management is a significant issue in my practice. 90(91%) *I frequently struggle with issues surrounding pain management. 78(79%) *I find successful pain management gratifying. 73(75%) *It is difficult to distinguish between managing pain and addiction. 68(69%) *Managing chronic pain is a priority at my site. 48(49%) *We adequately manage pain at my site. 23(23%)

17 It is difficult to manage pain in patients with a history of addiction. Pain management is a significant issue in my practice. I frequently struggle with issues surrounding pain management I find successful pain management gratifying. It is difficult to distinguish between managing pain and addiction Managing chronic pain is a priority at my site We adequately manage pain at my site HCH Clinician attitudes towards pain management (101 HCH clinician Network members in 2010) 91% 91% 79% 75% 69% 49% 23%

18 Pain is a universal experience but unique to each individual. Recommended adaptations for HCH HISTORY Focus primarily on fostering a therapeutic alliance at the initial encounter. Use the initial visit as a critical opportunity to engage the patient and establish trust. Ask about physical and mental health (including history of traumatic brain injury/ substance use), history of chronic pain, and living situation (including residential stability). PHYSICAL EXAMINATION Defer the physical examination to the second visit, if needed; or keep the initial exam focused on the area of concern. Perform serial focused exams (as tolerated), if needed. Look for evidence of occult alcoholism or addiction. Practice Trauma-Informed Care during the physical examination and in all patient encounters, recognizing that individuals who are homeless are likely to have experienced some form of previous trauma.

19 History questions: Pain location, intensity, quality, onset/duration/variations/rhythms, manner of expressing pain, pain relief, what makes it worse Severity: on a scale of 1 to 10 ; Wong- Baker smiley to sad faces, pain thermometer Structured instruments: Brief pain inventory, McGill pain questionnaire (also brief version)

20 Pain interference with usual activities, activities of daily living, work/looking for work activities, social activities. Roland-Morris and Oswestry low back pain scales: personal care, lifting, walking, sitting, standing, sleeping, social life, traveling, working Also part of the brief pain inventory

21 Strong association of chronic pain with depression and anxiety Underlying mental illness also common in homeless population, can be exacerbated by chronic pain Depression: PHQ-9 Anxiety: Beck anxiety inventory

22 May help guide medication management Categories include: Neuropathic (diabetic neuropathy, fibromyalgia) Muscle pain (myofascial pain syndromes) Inflammatory (rheumatoid arthritis) Mechanical (osteoarthritis, degenerative joint)

23 The elephant in the room when managing chronic pain One alternative: never prescribe addictive substances Another alternative: Assess for known substance abuse Assess for risk of abuse Assess for history of buying, selling drugs Assess for known or suspected mental illness Make a decision based on individual patient, program resources and state law.

24 Increased risk for misuse with (Opioid Risk Tool): Family history of substance abuse (esp. prescription drugs) Personal history of substance abuse (esp. prescription drugs) Age between If a woman, history of childhood sexual abuse Psychological disease (esp. ADHD, OCD, BAD, schizophrenia, less so depression/anxiety) Consider using a urine drug test (UDT) as part of initial assessment.

25 Know your state law: May require second opinions, urine drug testing, pharmacy records reviews, special record keeping Know your clinical expertise (dosing, side effect management, etc.) Know your ability to work as a team Use a universal precautions approach Know your patients Can your patients purchase or get opioids on a regular basis? Can your patients store their opioids safely? Can your patients manage side effects?

26 If the pain was curable, someone would probably have fixed it by now. A good assessment and physical exam will assure that no redflags are raised for life threatening or correctable causes. Don t skimp on a good history and exam, Don t rush to expensive testing. MRIs are not curative Care Plans Function! Comfort! Acceptance!

27 Jointly identify indicators of functional improvement with the patient to help determine whether the plan of care is working. Develop a plan emphasizing holistic treatment with multiple modalities; Assure patient understanding of the treatment plan; Modify in response to functional change or if problems arise Determine the patient s stage of change and how behavioral health problems are contributing to chronic pain. Include a behavioral health care plan in the plan of care.

28 Review fundamental concepts of chronic pain management at every visit. Consider group visits as a vehicle for patient education; develop a core curriculum for all patients supplemented by special groups for those with higher needs. Educate providers about prescribing opioid analgesics to homeless persons with substance use disorders and adaptation of prescribing/ dispensing practices, as needed. Emphasize setting reasonable, attainable, short-term self-management goals while working toward longterm goals. Use motivational enhancement techniques to help patients resolve ambivalence about behavioral change.

29 Select treatment based on context and available resources. Encourage early and ongoing non-pharmacologic treatment. Address psychosocial needs. Choose non-opioid pharmacologic interventions based on etiology of pain, co-morbid conditions, medications, and other factors, some of which are more common among homeless people.

30 Behavioral modalities Appropriate goal setting What are functional goals (walk 2 blocks, work at the factory, pick up my kids) What are comfort goals (able to sleep at night, pain I can ignore at times, pain at 3/10) Acceptance: Together, we can decrease your pain and increase your ability to do some of the things you want to do. Physical modalities: Exercise instruction, info sheets, proper body mechanics Classes, group sessions (tai chi, yoga, exercise, etc.) Physical therapy Massage therapy, acupuncture

31 Treat existing co-morbidities Mental illness CBT, psychiatry, medications Substance abuse Other chronic diseases (diabetes, etc.) Medications Analgesics (pain killers) Adjunct medications Anti-seizure medications Anti-depressants Anxiolytics Muscle relaxers Topical agents Specific meds (triptans for migraines, steriods, etc)

32 Always return to the care plan Are functional goals being met? Are comfort goals being met? Are co-morbidities (including mental illness and substance abuse and other health problems) an issues? If opioids are being used Remember universal precautions Consider pill counts, UDT, second opinions with specialists and other team members Remember the effect of homelessness on all health!!

33 Tell me about your pain? How bad it is? How does it limit what you want to do? By understanding your pain better, we can help you feel better. My neck has hurt ever since my motorcycle crash in You got to help me, Doc!

34 When I was working and had insurance, my headaches were under control with cymbalta, topamax, massage therapy, botox injections and weekly relaxation therapy sessions with my personal trainer. Now I don t have anything and I can t stand the pain! How frustrating for you! We don t have all those options available, but by understanding your pain better, we will work with you to decrease your pain and improve your ability to do

35 Some of the factors associated with homelessness are the same factors that are associated with increased pain and decreased treatment. CNMP Management requires thorough pain, functional and psychosocial assessments and reassessments CNMP treatments include physical modalities, counseling and mental health, biopsychosocialspiritual support, and medications

36 Medications include analgesics as well as adjunct medications Chronic opioid use requires that a program be able to: Assess patients for abuse and diversion potential Monitor patients following state law Assure patients can access and safely store medications manage patients side effects

37 Recommendations for the Care of Homeless Adults with Chronic non-malignant Pain ChronicPainManagement.pdf National Guidelines Clearinghouse Assessment and Management of Chronic Pain pain chronic assessment_and_management_of _14399/ pain chronic assessment_and_management_of guideline_.html Relieving pain in America Reports/2011/Relieving-Pain-in-America-A- Blueprint-for-Transforming-Prevention-Care-

38 Treating a pain patient can be like fixing a car with four flat tires. You cannot just inflate one tire and expect a good result. You must work on all four. Relieving Pain in America, Institute of Medicine, 2011 Thank you Nancy C. Elder, MD nancy.elder@uc.edu