is persistent (chronic) pain a preventable disease ruben halperin, md mph may 31, 2014
TRANSCRIPT
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Is Persistent (Chronic) Pain a Preventable Disease
Ruben Halperin, MD MPHMay 31, 2014
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Conflict of Interest DisclosureRuben Halperin, MD MPH
Has no real or apparent conflicts of interest to report.
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Objectives
• Understand the:– Current paradigm for treatment of persistent pain– New biopsychosocial paradigm for evaluation and
treatment and maybe predicting and preventing persistent pain
– Risks and benefits of opioid treatment• Public health & individual health
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Chronic Pain Treatment? How Did We Get Here?
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The Old Cartesian Model
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Risks vs. Benefits
Public Health Individual Health
What do we know about the risks and benefits of chronic opioids?
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Risk vs. Benefit
What is the benefit we are seeking?– Better function?– Decreased suffering?– Improved Quality of
Life?
What risks are we willing to take?
?
100,000,000 people in the US have Chronic pain. An effective treatment might be worth some risk. . . . . .if that treatment worked
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Risks of Opioids to Individuals are Well Known
• Dependence• Addiction• Overdose death• Ventilatory Impairment/ Central sleep apnea• Narcotic Bowel Syndrome• Opioid endocrinopathy• Opioid induced hyperalgesia
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A 30 Year Public Health Experiment
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Death is Not the Only Issue
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2010 Cost of Non-Medical Use of Opioids
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Do Opioids Improve Function, Decrease Suffering and Improve Quality of Life?
“Ask your doctor if taking a pill to solve all your problems is right for you.”
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Danish Epidemiologic StudyN=1906 : opioid users vs. matched controls
• Opioid use significantly associated with physical activities levels of employment self-rated health self-rated QOL by SF-36
self-reported severe pain
Eriksen et al. Pain 2003
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Kaiser NW Study
Longer duration of opioid use associated with:DepressionAnxietyPTSDSubstance AbuseSedative-hypnotic useEscalating doses of opioids
Deyo et al. JABFM 2011
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CONsortium to Study Opioid Risks and TrendsGroup Health + KP Northern CA
For > 100 mg HR 8.87 (3.99 – 19.72) for all overdose events
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VA/Univ. of MichiganOpioid Prescribing and Overdose
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Cochrane review 2013
• 31 studies, 1237 subjects, – 10 different opioids
• Short term studies:– lasting up to 1 day
• Intermediate studies – – Up to 12 weeks– Median 28 days ( 8 – 70)
• 1˚ Outcome ≥ 30 or ≥ 50%↓ pain from baseline
• Short term – no difference• Intermediate term– Opioids better than
placebo for pain reduction ≥ 30% and 50%
– No difference in physical functioning
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Efficacy of Opioid Withdrawal + Pain Rehabilitation
Mayo Clinic N = 373• 213 taking opioids, 160 not taking– Mean pain duration 9.4 years
• 3 week intensive outpatient interdisciplinary program + opioid withdrawal
• Follow-up post treatment and at 6 months
Townsend et al. Pain 2008
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Outcome variable Pretreatment Posttreatment 6 months
Opioids No opioids
Opioids No opioids
Opioids No opioids
Mean (SD)
Depression* 29.3 (12.4)
24.8 (12.5)
16.3 (11.7)
14.7 (10.7)
17.8 (13.4)
16.9 (11.6)
Catastrophizing* 28.3(11.5)
25.3 (13.1)
12.9 (11.0)
12.1 (12.3)
13.9 (11.4)
13.1 (11.2)
Pain severity* 49.3 (8.6)
46.2 (10.3)
40.0 (12.9)
37.2 (13.8)
39.1 (14.5)
38.2 (14.7)
Activity level* 52.0 (8.9)
52.7 (9.5)
58.4 (10.3)
57.9 (9.9)
58.2 (10.6)
57.7 (10.5)
Health perception* 34.8
(12.7)36.5 (12.7)
42.4 (12.7)
43.0 (11.6)
41.3 (12.3)
39.7 (12.9)
Physicalfunctioning*
28.2 (13.9)
30.4 (14.9)
39.7 (12.2)
41.2 (12.3)
37.8 (13.6)
38.9 (14.7)
*p<00.1 pre to post treatment
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It’s Time to Move Beyond Opioids
Infinity
Opioids
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A New Paradigm
If opioids aren’t the answer, then what?
PAIN IS AN OUTPUT FROM THE BRAIN
ALL PAIN IS REAL PAIN
PAIN ≠ HARM
TISSUE DAMAGE (nociception) IS NEITHER NECESSARY NOR SUFFICIENT FOR PAIN
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Fear Avoidance Model
Vlaeyen (2000)
Sympathetic Tone, Cortisol
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Catastrophizing
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The Keele STarT Back Screening Tool Agree Disagree
1My back pain has spread down my leg(s) at some time in the last 2 weeks □ □
2 I have had pain in the shoulder or neck at some time in the last 2 weeks □ □
3 I have only walked short distances because of my back pain □ □
4In the last 2 weeks, I have dressed more slowly than usual because of back pain
□ □
5It’s not really safe for a person with a condition like mine to be physically active
□ □
6 Worrying thoughts have been going through my mind a lot of the time □ □
7I feel that my back pain is terrible and it’s never going to get any better □ □
8 In general I have not enjoyed all the things I used to enjoy □ □
9 Overall, how bothersome has your back pain been in the last 2 weeks?
not at all slightly moderately very much extremely
© Keele University 01/08/07
Total score (all 9): __________________ Sub Score (Q5-9):______________
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Pain Catastrophizing Scale PCS
Total _______
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PCS Implications
• 30 is 75th percentile - normal distribution sample of injured workers in Nova Scotia who filed work-comp claim
• At a score > 30– 70% remain unemployed one year post injury– 70% describe themselves as totally disabled– 66% scored > 16 on Beck Depression Index
(moderate depression)
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Fear and Catastrophizing in the Development of Persistent Pain
• Self-Perceived disability, but not pain intensity at 2 months predicts disability at 6 and 12 months1
• Psychological factors and opioid use predict disability 2 mos. after skeletal trauma2
• Catastrophizing was the sole independent predictor of disability at 5-8 mos.2
• Severity of injury and extent of surgery did not predict disability at 2 mos. Or 5-8 mos. 2
1 Epping-jordan et al. Health Psych 19982 Vranceau AM et al. J Bone Joint Surg Am. 2014 Feb
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Catastrophizing
Pain Catastrophizing associated withPain intensityPain related activity interferenceDisabilityDepressionAlterations in social support networks
Severeijns et al Clinical J Pain, 2001
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Catastrophizing Predicts Poor Surgical Outcomes
Pre- TKA, ↑ catastrophizing associated with: post- op pain rating1,2,3 increased disability1,2,3
increased opioid usage2
increased length of hospital stay3
1Riddle D et al. Clin Orthop Relat Res. Mar 20102Forsythe ME et al. Pain Res Manag. Jul-Aug 20083 Vitvwrow E et al. Knee Surg Sports Traumatol Arthrosc 2009
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Changing Beliefs Changes Function
• 141 patients, 3 week multidisciplinary pain treatment (UW)↓ catastrophizing, ↓ belief that pain = harm, ↓belief that one is disabled
self-report disability, pain intensity depression
Jensen MP et al. Pain 2001Jensen MP et al. Pain 2007
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Catastrophizing and fear avoidance can be treated
• Engaged, activated patient• Multidisciplinary team • Behavioral health intervention• Pain education / cognitive change of faulty
beliefs• Return to activity/pacing• Self-management/self-soothing techniques
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More Importantly
• Identifying Catastrophizing and Fear early can help us predict who is at risk for developing persistent pain
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Questions?