![Page 1: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/1.jpg)
THE PAIN DECADE AND THE THE PAIN DECADE AND THE PUBLIC HEALTHPUBLIC HEALTH
THE PAIN DECADE AND THE THE PAIN DECADE AND THE PUBLIC HEALTHPUBLIC HEALTH
Rollin M. Gallagher, MD, MPH
Clinical Professor, Departments of Anesthesiology and PsychiatryUniversity 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
Rollin M. Gallagher, MD, MPH
Clinical Professor, Departments of Anesthesiology and PsychiatryUniversity 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
![Page 2: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/2.jpg)
The Pain Decade and the Public HealthThe Pain Decade and the Public HealthThe Pain Decade and the Public HealthThe 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
•History– Conceptualization – Lippe, Saper,
Ashburn et al, 1999– Matriculation – SB 3163– Enrollment – October 28, 2000– Life span – 2001 - 2010
![Page 3: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/3.jpg)
“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
Albert S. Schweitzer, 1931
On the Edge of the Primeval Forest.
New York: Macmillan, 1931:652
![Page 4: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/4.jpg)
Pain MedicinePain MedicineHistoryHistory
Pain MedicinePain MedicineHistoryHistory
• Epochs
– Antiquity to 19th Century
•Pain a symptom treated by purgation
•Dichotomy of pain – Descartes and Byron
– Physical pain– Mental pain
• Epochs
– Antiquity to 19th Century
•Pain a symptom treated by purgation
•Dichotomy of pain – Descartes and Byron
– Physical pain– Mental pain
![Page 5: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/5.jpg)
Pain MedicinePain MedicineHistoryHistory
Pain MedicinePain MedicineHistoryHistory
•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
•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
![Page 6: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/6.jpg)
Pain Medicine HistoryPain Medicine HistoryPain Medicine HistoryPain 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
•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
![Page 7: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/7.jpg)
Neuropathic low back pain
DIAGNOSIS There Are Many Painful Diseases and Pain Diseases
DIAGNOSIS There Are Many Painful Diseases and Pain Diseases
*Complex regional pain syndrome.
Nociceptive painCaused by activity inneural pathways in
response to potentiallytissue-damaging stimuli
Neuropathic painInitiated or caused by a
primary lesion or dysfunction
in the nervous system
Postoperativepain
Mechanicallow back pain
Sickle cellcrisis
Arthritis
Peripheralneuropathy
Postherpeticneuralgia
Diabeticneuropathy
Sports/Exerciseinjuries
Central post-stroke pain
Trigeminalneuralgia
Inflammatory / Immunological Mediation
CANCER PAIN, LBP, CHRONIC FACIAL PAIN
(mixed pain states)
SENSITIZATIONCRPS*
Phantom tooth pain
![Page 8: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/8.jpg)
Phenomenological Model of Pain Disease: Post Herpetic Neuralgia Phenomenological Model of Pain Disease: Post Herpetic Neuralgia
Exposure to VaricellaVirus
ChickenPox with Infection,with invasionof dorsal root ganglion& spinalnerves in childhood
“Shingles”
Activation of virus and disease of acute herpes zoster
PrecipitatingFactors:
Acute illness,Stress, Age,Immuno-Suppression,Cancer.
Risk factors for chronic pain:
Severity and duration of acute rash, Pain severity, Anxiety severity.
*
PredisposingCondition
Post-herpetic Neuralgia
Successful Pain Control
*
Factors reducing risk for PHN:
Early anti-viral treatment, Early amitriptylene, Good pain control.
Factors enhancing good outcome:
Access to appropriate pain treatment
Access to rehabilitation.
BPS
OUTCOMES
Initial exposure
![Page 9: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/9.jpg)
Mismanaged chronic pain is often a personal catastrophe! ….and is
a huge public health problem.
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
• 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
• Psychological morbidity– Fear, anger, suffering– Sleep disturbances– Loss of self-esteem
• Medical comorbidites & consequences– Accidents– Medication effects– Immune function– Clinical depression
• Societal consequences- Health care costs- Disability
- Lost workdays- Business failures- Higher taxes
Established effects (by research) of chronic pain
Pain causes these problems.
These problems reduce the effectiveness of pain treatment.
They must be managed to obtain good treatment outcomes
![Page 10: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/10.jpg)
Depression and Pain ComorbidityDepression and Pain Comorbidity
ResponseRemission
Symptoms
Syndrome
Recovery
ContinuationAcute
Relapse
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
Treatment Phases
“Normalcy”
Maintenance
Relapse RecurrenceProgression
to disorder
Pain
Pain, A condition or symptom that causes or activates depression
![Page 11: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/11.jpg)
Pain MedicinePain MedicineHistoryHistory
Pain MedicinePain MedicineHistoryHistory
•Epochs– Late 20th Century to 2007
•Rise of Neuroscience and Biotechnology
– Gate theory– Molecular biology and neurotransmitters– Psychopharmacology– Neuropharmacology – Neuromodulation– disease
•Epochs– Late 20th Century to 2007
•Rise of Neuroscience and Biotechnology
– Gate theory– Molecular biology and neurotransmitters– Psychopharmacology– Neuropharmacology – Neuromodulation– disease
![Page 12: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/12.jpg)
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.
• 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.
![Page 13: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/13.jpg)
The Polytrauma ChallengeThe 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
• 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
![Page 14: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/14.jpg)
C fiber
Abeta fiber
Nerve injury
PhenotypicalChanges
Spinal cord Damage
Neuro-plasticity
Central sensitization
Alteration of modulatory
systems
Ectopic discharge
Ectopic discharge
Adapted from Woolf & Mannion, Lancet 1999Attal & Bouhassira, Acta Neurol Scand 1999
ANS activation <<< Stress <<< Pain <<< BRAIN PROCESSING
+++
Limb trauma
![Page 15: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/15.jpg)
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 Pain 1989)
• Predictors of poor outcome at 3 months post-injury:• Acute pain intensity, anxiety, depression and sleep disturbance
Does early intervention make a difference?
Castillo et al. Pain 124 (2006): 321-329
![Page 16: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/16.jpg)
Opioid protective effectOpioid 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.”
• 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.”
![Page 17: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/17.jpg)
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, MDGeselle McKnight, CRNP
Alexander Stojadinovic, MD
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, MDGeselle McKnight, CRNP
Alexander Stojadinovic, MD
![Page 18: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/18.jpg)
![Page 19: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/19.jpg)
THE END: CPRS Pain Cycle THE END: CPRS Pain Cycle Pathology:-Muscle atrophy, weakness;-Bone demineralization;-Depression
Less activeKinesophobiaDecreased motivationIncreased isolationRole loss
Disability
Pathophysiology of Maintenance:-Radiculopathy-Neuroma traction-Myofascial sensitization-Brain pathology (loss, reorganization)
Psychopathologyof maintenance:-Encoded anxiety dysregulation - PTSD-Emotional allodynia-Mood disorder
NeurogenicInflammation:- Glial activation- Pro-inflammatory cytokines- blood-nerve barrier dysruption
Acute injuryand pain
PeripheralSensitization:Na+ channelsLower threshold
Central sensitization
![Page 20: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/20.jpg)
PNS
NA channels Lidocaine Patch 5%CarbamazepineOxycarbazineTricyclicsTopiramate
Spinal cord
BRAINModulation byNorepinephrineSerotoninEndogenous opiates
Tricyclics, SSRIs, SNRIs (Venlafaxine, Duloxetine),Tramadol, Opiates
Voltage gated Ca channels (L & PQ presynaptic): Gabapentin, Pregabalin
Mechanism Targets For Neuropathic Pain Pharmacotherapy
2 agonistsTizanidineClonidine
(Adapted from Beydoun 2001)
Anti-inflammatoryNSAID, Cox 2
NMDA antagonists: Ketamine, Dextromethorphan
![Page 21: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/21.jpg)
Pain MedicinePain MedicineHistoryHistoryPain MedicinePain MedicineHistoryHistory
• 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
• 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
![Page 22: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/22.jpg)
The tertiary, sequential care modelThe tertiary, sequential care model
INJURY/SYMPTOMEmergencyServices Primary
CareSpecialty Office #1
Specialty Office #2
Specialty Office #3
TREATMENTFAILURES
Specialty Office #4
ALTERNATIVE TREATMENTS
TIME1
11
3
4
5
4
(6)
22
3
3
4 (5)
Gallagher RM. Med Clin N Am 83(5): 555-585, 1999.
CHASING THE SYMPTOM THROUGH A REDUCTIONISTIC,
BIOMEDICAL MODEL
![Page 23: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/23.jpg)
The multi-disciplinary, biobehavioralpain center modelINJURY/SYMPTOM
EmergencyServices Primary
CareSpecialty Offices, Alternative CareTreatment
FailureTreatment
Success
MultidisciplinaryPain Center: MD, PT, OT, Behav Med, Voc Rehab
1
2 2
3
4
5
time
1 1
![Page 24: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/24.jpg)
The managed primary care modelThe managed primary care model
INJURY/SYMPTOM
PrimaryCare Office
EmergencyServices
Specialty OfficesTreatment
Failures
time
JOB LOSSINSURANCE LOSS
11
2
(3)
3 (4)
5
6
2
Gallagher RM. Med Clin N Am 83(5): 555-585, 1999.
DOES NOT WORK FOR PATIENTS OR POPULATIONS
JUST SAY NO!!
![Page 25: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/25.jpg)
Cost vs. QualityCost vs. Quality
RReessoouurrccee
Quality of care (outcomes)Quality of care (outcomes)
Excess careExcess care
Best practiceBest practice
(From W. Brose, MD)
![Page 26: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/26.jpg)
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
![Page 27: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/27.jpg)
Pain medicine and primary care community rehabilitation model
Pain medicine and primary care community rehabilitation model
INJURY/SYMPTOM
EmergencyServices
PrimaryCare: ClinicalAlgorithms
Recurrent or persistent pain impairing functionIntegrated
Pain MedicineEval & Services:Med. trials, PT, Blocks, Behavioral mgmt.
Sub-specialtyEval. & mgmt.
Treatment Failure
Multidisc-iplinary
Pain Center
1
2
3
(4)5
6
6
7
CommunitySupport &Services (PT, OT, Voc,behavioral, pharmacy)
Gallagher RM. Med Clin N Am 83(5): 555-585, 1999.
.
3
![Page 28: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/28.jpg)
Nociceptivepain
Neuropathicpain
Pain condition +
depressionSecondary sleep
disturbance
Secondary depression Primary D.
NSAIDs,Cox-IIs,opioids,
lidocaine p.? doxepin cr.?
Persists afteradequateanalgesia
Persists afteradequateanalgesia
Evaluate risks
Evaluate risks
Antihistamine,zolpidem,
etc.
Trazodone
Low-doseTCA
Lidocaine patch;gabapentin & other
AED (Ca+ & Na+ channels); alpha 2 agonists
(tizanidine, clonidine);opioids
Titrate TCAs (Na+ channels and SNRI) :
desipramine, nortriptyline,
SSRI trial
Evaluate risksSNRIs: venlafaxine,
duloxetine
Algorithm for Medication Selection in Chronic Pain With and Without Comorbid Depression
Algorithm for Medication Selection in Chronic Pain With and Without Comorbid Depression
Adapted from Gallagher RM, Verma S. Semin Clin Neurosurgery. 2004.This information concerns uses that have not been approved by the US FDA.
Evaluate risks
![Page 29: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/29.jpg)
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 2007
Aberrant Behavior Categories over one year
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 2007
Aberrant Behavior Categories over one year
Referred for Addiction Treatment
13%
Aberrant Behavior Resolved
33%Self Discharged32%
Possible Diversion4%
Still Monitoring w/ Aberrancy
18%
Referred for Aberrant Behavior
n=170
Referred for Addiction Treatment
13%
Aberrant Behavior Resolved
33%Self Discharged32%
Possible Diversion4%
Still Monitoring w/ Aberrancy
18%
Referred for Aberrant Behavior
n=170
![Page 30: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/30.jpg)
OUR CONUNDRUMOUR CONUNDRUMGrowing societal awareness of:
1. the prevalence of inadequately treated chronic pain 2. its impact on society3. the need for access to effective pain treatment
vs
Growing societal awareness of: 1. The rapidly increasing rate of use of opioid prescriptions2. The increasing rate of prescription drug abuse3. The increasing rate of prescription drug abuse deaths
Growing societal awareness of: 1. the prevalence of inadequately treated chronic pain 2. its impact on society3. the need for access to effective pain treatment
vs
Growing societal awareness of: 1. The rapidly increasing rate of use of opioid prescriptions2. The increasing rate of prescription drug abuse3. The increasing rate of prescription drug abuse deaths
![Page 31: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/31.jpg)
Balanced Pain Policy Initiative Center for Practical Bioethics
Kansas City, MO
Balanced Pain Policy Initiative Center for Practical Bioethics
Kansas 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
• 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
![Page 32: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/32.jpg)
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).
![Page 33: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/33.jpg)
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
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
![Page 34: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/34.jpg)
Decade of Pain Control and ResearchDecade of Pain Control and ResearchDecade of Pain Control and ResearchDecade 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
• Goals: To Promote Pain Medicine– Research– Education– Clinical Practice– Advocacy & Policy Development
•How are we doing after 6 years?•A snapshot
![Page 35: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/35.jpg)
Growth in the Number of Published Articles on Pain over the Past 30 years. (Source: June 10, 2003, Pub Med search
with keyword pain)
Growth in the Number of Published Articles on Pain over the Past 30 years. (Source: June 10, 2003, Pub Med search
with keyword pain)
Articles Published, by Decade, Retrieved Using PubMed with Keyword "Pain"
30,138
60,421
105,828
0
20,000
40,000
60,000
80,000
100,000
120,000
1970-1979 1980-1989 1990-1999
Decade
Nu
mb
er o
f A
rtic
les Keyword: Pain
Articles Published, by Decade, Retrieved Using PubMed with Keyword "Pain"
30,138
60,421
105,828
0
20,000
40,000
60,000
80,000
100,000
120,000
1970-1979 1980-1989 1990-1999
Decade
Nu
mb
er o
f A
rtic
les Keyword: Pain
Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004
![Page 36: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/36.jpg)
Growth in the Number of Published Articles on Nociception over the Past 30 years. (Source: June 10, 2003, Plumbed search with
keyword nociception)
Growth in the Number of Published Articles on Nociception over the Past 30 years. (Source: June 10, 2003, Plumbed search with
keyword nociception)
Articles Published, by Decade, Using PubMed with Keyword "Nociception"
1,391
532
45
0
200
400
600
800
1000
1200
1400
1600
1970-1979 1980-1989 1990-1999
Decade
Nu
mb
er o
f A
rtic
les
Keyword: Nociception
Articles Published, by Decade, Using PubMed with Keyword "Nociception"
1,391
532
45
0
200
400
600
800
1000
1200
1400
1600
1970-1979 1980-1989 1990-1999
Decade
Nu
mb
er o
f A
rtic
les
Keyword: Nociception
Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004
![Page 37: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/37.jpg)
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)
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%
![Page 38: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/38.jpg)
Journal proliferationJournal 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. 2.477Increased to six issues yearly in 2005Increased to eight issues in 2007Increase 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
• 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. 2.477Increased to six issues yearly in 2005Increased to eight issues in 2007Increase 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
![Page 39: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/39.jpg)
NIH Research InitiativesNIH 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?
• 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?
![Page 40: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/40.jpg)
VA-military InitiativesVA-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
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
![Page 41: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/41.jpg)
COMMUNITY HEALTH SYSTEM
VETERANS HEALTH SYSTEM
COMMUNITY SUPPORT SYSTEM
MILITARY HOSPITAL, USA
MILITARY BASE CLINIC, USA
Transition to Community Care:
Pain Medicine and Mental
Health Services
![Page 42: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/42.jpg)
SOCIETAL INTERESTSOCIETAL INTEREST
• Non-profit advocacy organizations:
– American Chronic Pain Association
– National Pain Foundation: • www.nationalpainfoundation.org
– American Pain Foundation:• www.painfoundation.org
• Non-profit advocacy organizations:
– American Chronic Pain Association
– National Pain Foundation: • www.nationalpainfoundation.org
– American Pain Foundation:• www.painfoundation.org
![Page 43: THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania](https://reader036.vdocuments.site/reader036/viewer/2022070306/5519bc1d55034660578b49e1/html5/thumbnails/43.jpg)
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
• 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