Opioid Abuse Prevention Symposium Aram Mardian, MD Chief, Chronic Pain Wellness Center Phoenix VA Health CaRe System September 15, 2017
Objective Describe self-management as it relates to chronic pain and the opioid epidemic List 2 active treatments for chronic pain that are supported by evidence Discuss barriers and opportunities for implementing a whole person approach to chronic pain in the US healthcare system
Two Converging Public Health Crises Chronic Pain Opioid Crisis
2011 NAM Report: > 100 million Americans report having chronic pain $560-635 billion annual costs associated with chronic pain (direct medical costs and lost productivity)
1901 2017 1990s
Chronic Pain and Transformation of the Care Model Biomedical Care Model Find it and Fix it approach Assumes a 1:1 correlation between physical pathology and pain Patient is passive victim of identifiable disease and doctor is responsible for urgent and complete pain relief Focus on passive treatments that are done TO the patient 1980s-2000s Created a care system that is fragmented, costly, risky, and ineffective
Cultural Transformation to a Biopsychosocial Care Model Biopsychosocial Care Model Focus on care of the whole person Treat the person who has pain rather than focus on painful tissue Address social, psychological, and biological components of pain Focus on improving function Create physical, mental, social, spiritual health Patient is activated center of care team Focus on self-management and active treatments that depend on active patient participation
February 2017 3 Sections with 17 Recommendations regarding opioid use for chronic pain 1 Recommendation regarding use of opioids for acute pain Provider and Patient Summaries and Pocket Card 1. Initiation and Continuation of Opioids 2. Risk Mitigation 3.Type, Dose, Follow-up, and Taper of Opioids 4. Opioid Therapy for Acute Pain
Recommendation 1 a) We recommend against initiation of long-term opioid therapy for chronic pain. b) We recommend alternatives to opioid therapy such as selfmanagement strategies and other non-pharmacological treatments. c) When pharmacologic therapies are used, we recommend nonopioids over opioids.
What is locus of control? External vs Internal What are you going to do to fix my pain? vs what can I do to start managing my pain?
Active vs Passive therapies Passive therapies are therapies that someone else does TO the person with pain Medications Shots Surgery Massage Acupuncture Chiropractic Active therapies require effort of the person with pain and are not dependent on professionals Exercise/movement Application of coping skills Setting goals and taking actions to work towards goals Engaging in enjoyable, social, work, and volunteer activities
Evidence for Low Back Pain Therapies Medications 1 Limited evidence for short term benefit Injections 2 Limited evidence for very short term benefit of unclear clinical significance Surgery 3 Discectomy may provide benefit in well-selected pts with radiculopathy and prolapsed disc Symptomatic spinal stenosis may benefit from surgery, however interdisciplinary rehabilitation is preferred Failed Back Surgery Syndrome incidence may be up to 40% (1) Kuijpers 2011 (2) Chou 2015 (3) Chan 2011, Chou 2009, van Tulder 2006
Evidence for Low Back Pain Therapies Biopsychosocial rehabilitation 1 Small improvement in long term pain and disability Cognitive Behavioral Therapy 2 Moderate improvement in pain and disability Exercise 2 Moderate improvement in pain and disability (1) Kamper 2014 (2) Chou 2007
Treatment of comorbidities Optimized treatment of depression and pain self-management can improve pain in chronic MSK pain (Kroenke, JAMA, 2009) Weight reduction can lead to improvement in pain and pain related disability (Narouze, Reg Anesth Pain Med, 2015) Improved diabetic control can lead to improvement in neuropathic pain Improvement in sleep can lead to improvement in wellbeing and pain
Implementation
Barriers Episodic Single discipline Short term focus Disease focus Reductionism Single treatment focus: procedures or opioids Future Directions Longitudinal Team based Long term focus Wellness and Prevention Whole Person + environment Multimodal focus: Self-management + biopsychosocial treatment plan
Reimbursement Value cognitive work (time spent with patients) equally to procedural work Provide reimbursement for pain psychological services Provide economic incentives to provide integrated interdisciplinary care NPS: Tailor payment to promote and incentivize high-quality, coordinated pain care through an integrated biopsychosocial approach that is cost-effective, value-based, patient-centered, comprehensive, and improves outcomes for people with pain.
Focus on Treatment Teams Focus on functions rather than disciplines Case Manager (RN, SW) Movement therapy (PT, RT, KT, yoga therapist, etc) Behavioral therapy (psychologist, counselor) Health Coach (LPN, RN, RD, non-licensed) Addiction provider with ability to prescribe Medication Assisted Treatment PCP medical provider (MD/DO, NP, PA) May require virtual teams (ideally linked by care manager) Shared Medical Appointments Treatment and Education Groups Integrated Interprofessional Pain Rehabilitation
References Chan, C., & Peng, P. (2011). Failed back surgery syndrome. Pain Medicine, 12(4), 577 606. Chou, R., Deyo, R. A., Devine, B., Hansen, R., Sullivan, S., Jarvik, J. G.,Turner, J. (2014). The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012- 00014-I, Ed.). Rockville, MD: Agency for Healthcare Research Quality. Chou, R., Hashimoto, R., Friedly, J., Fu, R., Dana, T., Sullivan, S., Jarvik, J. (2015). Pain Management Injection Therapies for Low Back Pain. Technology Assessment Report ESIB0813. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA 290-2012-00014-I.). Rockville, MD: Agency for Healthcare Research Quality. Chou, R., Loeser, J., Owens, D., Rosenquist, R., Atlas, S., Baisden, Wall, E. M. (2009). Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine, 34(10), 1066 77. Kamper, S., Apeldoorn, A., A, C., Smeets, R., RWJG, O., Guzman, J., & MW, van T. (2014). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review). Cochrane Database of Systematic Reviews (Online), (9), 1 209. Kuijpers, T., van Middelkoop, M., Rubinstein, S. M., Ostelo, R., Verhagen, A., Koes, B. W., & van Tulder, M. W. (2011). A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. European Spine Journal, 20(1), 40 50. Van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. European Spine Journal, 15 Suppl 1, S82 92.