Multidisciplinary Approach to Pain ManagementSarah Endrizzi, MDAdvanced Pain ManagementMedical College of Wisconsin

Objectives• Epidemiology of chronic pain• Pain as a disease• What is multidisciplinary pain management

(MDPM)• Discuss goals of MDPM• Treatment modalities

▫Medications▫Interventions▫Pain psychology▫PT/OT▫Complimentary and alternative medicine

So why are you here?• Primary care MD/NPs are the predominant

providers managing pain in the US▫ Little previous teaching

Medical students receive on average <10 hours on pain physiology, neuroanatomy, physiology, diagnosis, management and treatment (Mezei et al, 2011)

Medical students receive on average 1 hr of education on analgesics (Institute of Medicine Report, 2011)

Housestaff education in pain management is not substantially better (Ogle et al, 2008)

2013 Hurley©

Pain Epidemiology and Impact•100 million adults in the US with chronic

pain(Medical expediture panel, 2008)

•#1 cause for disability•Patients with pain cost ~$4,500/year

more than match no pain controls(Iom, 2011)

▫Direct medical costs - $293,000,000,000▫Back Pain was 72% of these costs▫Approximately 150 million work days lost

per year because of back pain

Comparison to Other Diseases•Direct and Indirect Costs in Billions(IOM, 2011)

▫Pain - $635▫Cardiovascular – $309 ▫Cancer - $243▫Trauma/Poisoning - $209▫Endocrine/metabolic - $127▫Digestive System - $112▫Respiratory System - $112

Why is proper evaluation and treatment of chronic pain important?•Chronic pain itself is a disease

▫Anatomical changes▫Physiological changes▫Pharmacological changes▫Psychological changes▫Altered responsiveness to medications

Chronic Pain State•Cortical thinning in CLBP compared to

controls

•Reversal of cortical thinning with treatment of pain

•Reversal of cortical thinning with treatment

Seminowizc, 2011, J Neurosci

Central Pain Disorders•Fibromyalgia•Post-stroke pain•Headache (tension>migraine)•Chronic pelvic Pain•Chronic Low Back Pain•Myofascial Pain/Widespread Chronic Pain•TMJD•Interstitial Cystitis

Phillips & Clauw. 2011

Development of chronic pain

•Pain that remains after the expected healing from an injury

•Pain that is NOT exclusively peripherally driven•Central Nervous System amplifies and distorts

the painful response so that it no longer is directly related to the peripheral input or stimulus

•An uncoupling of the expected stimulus-response relationship

Chicken or the egg?

•Are the differences pre-existing?▫Do they predispose patients to chronic pain

•Do they result from chronic medication exposure?

•Are they the result of anxiety, depression, decreased physical activity, reduced social and intellectual stimulation?

What is Multidisciplinary Pain Management (MDPM)?• Multiple Providers of various specialties who

work together to assess and develop a comprehensive treatment plan for a patient

• Often includes Medicine, psychology, & PT/OT• May also include alternative medicine

▫Massage▫Acupuncture▫Chiropractic

Why MDPM?•Because many Chronic Pain Disorders are

disease states•Many Pain states coexist with depression

& anxiety•We can’t treat all of these changes with

one modality•We are in the midst of an opioid addiction

epidemic

Goals in Multidisciplinary Pain Management•Improve or Maintain physical functioning•Facilitate Re-engagement in typical

activities ▫Maintain or return to employment▫Perform ADLs▫Ability to participate in leisure activities

•Making Removal of Pain as a primary goal can be counter productive

Engaging patients in their treatment plans•Discuss risk/benefits for all interventions•Offer options•Provide realistic, incremental goals•UTILIZE PAIN PSYCHOLOGY!!

Medications•Focus on non-opioid options

Membrane stabilizers NSAIDs Topicals Antidepressants

•Wean current opioid regimen

Results of Opioid Weaning

Harden et al. Pain Medicine 2015

Interventions•Done under fluoroscopy or ultrasound•Epidural steroid injections•Joint injections•Nerve ablations•Sympathetic blocks•Spinal cord stimulators•IT pumps

Pain Psychology•18-85% of patients with chronic pain have

a comorbid psychiatric condition (Doan, Neural Plasticity, 2015)

•35% with Chronic back/neck pain have depression or anxiety disorder (Katz, Spine.

1997,1999)•Correlation between severity of pain and

degree of depression (Fishbain, CJ of Pain, 1997)

•Cognitive approaches include CBT, biofeedback, hypnosis

PT/OT•Physical Therapist/Occupation Therapist

▫Educate on physiological basis of pain▫Teaches body mechanics, pacing▫Role in physical rehabilitation▫Address vocational issues▫Techniques for managing pain on the job

Gatchel, Am Psychologist. 2014

Physical Therapy•Active Treatment (better evidence)

▫Gait Training▫Core Strengthening and stability▫Postural re-education

•Passive Treatment (less evidence)▫TENS▫Heat/ Cold▫Ultrasound

CAM Therapies•Acupuncture

▫Improvement in Pain, but not long lasting (Furlan 2010)

•Massage▫Little Evidence to support use (Furlan. Cochrane

2015)

•Manipulation▫Better than placebo at improving pain,

function (Furlan 2010)

•Yoga and tai chi

• Facet RF: Cohen et al. CJP 2007• Spine surgery: Quigley Surg Neurol 1998, Jacobs Eur

Spine J 2011• Epidural steroids: Kwon et al. Skel Radiol 2007, Benzon

Pain 1984• Pharmacotherapy for CRPS: Perez et al. Pain 2003• IA injections for knee OA: Tanaka et al. Rheum Int 2002• Physical therapy for DJD: Jansen et al. Eur J Phys Rehabil

Med 2010• Vertebroplasty: Ryu & Park J Korean Neurosurg Soc 2009

TAKE HOME MESSAGE….SEND PATIENTS EARLY….

Prolonged duration of Pain Worsens Outcomes

Thank you!

Pain Centers of Wisconsin- Wauwatosa Clinic

Medical College of Wisconsin in partnership with Advanced Pain Management

959 N Mayfair RoadWauwatosa, WI 53226