Integrative Pain Care:focus on non-opioid modalities

Palmer MacKie

Integrative Pain Program

Eskenazi Health

Dept. of Medicine, IUSOM

I wish I could show you, when you are lonely or in

darkness, the astonishing light of

your own being

Hafiz

Objectives

1. View Pain care as social not simply a clinical entity

2. Identify and address all three domains of Pain

3. Polymodal Therapy is optimal:– Education(mind), participation(body),creative(spirit)

4. Yoga, CBT, Hypnosis, Acupuncture and oral CAM all have evidence and their place but nothing trumps….

5. Therapeutic Relationship allows:– Education, expectation and engagement

Philosophy and Goals

Pain is unavoidable, suffering is modifiable

• Primary Goals are Two:– Reduce pain and suffering– Increase functioning

• Employ poly-modal approach• Feelings, beliefs, thoughts and actions

– We possess ability to use these to create negative feedback loops that entrench pain and suffering. Thankfully, the reverse is true.

Willing, motivated Partner

Clin J Pain Vol. 24, No.4, May 2008

Sensory

EvaluativeAffective

Components of Persistent Pain

Control not Cure

Treatment Options

• EDUCATION• Progressive Exercise

– Aerobic– Strength– Range of motion

• Rehabilitation Medicine

• Massage• Acupuncture• Psychological• Heat, TENS, ice

• Co-analgesics • Relaxation Response• C B T• Non-opioid medicine• Chiropractic• Cranio-sacral• Nutrition• Yoga /Tai Chi/Qi qong• Hypnosis / biofeedback• Mindfulness Meditation• EDUCATION

Only need to exercise on days you eat

NeuroImage 23 (2004) 392–401

Lumbar instrumented fusion compared with cognitiveintervention and exercises in patients with chronic back pain

A prospective randomized controlled study

• For patients with chronic low back pain after previous surgery for disc herniation

• The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group

– lumbar fusion failed to show any benefit over cognitive intervention and exercises.

J.I. Brox et al. Pain 122 (2006) 145–155

Stepped Care for Affective disorders and Musculoskeletal Pain (SCAMP)

• Randomized Controlled Trial• Intervention : 12 wk plus 12 wk

– Optimize depression then 6 Pain self-management• Outcomes: determined at 12 months

– Hopkins Symptom Check list-20– Pain Severity– Global Improvement in Pain– Pain Interference

JAMA 2009;301(20):2099-2110

SCAMP results

1. > 50 % reduction in depression– 37% vs. 16% RR 2.3

2. > 30% reduction in pain– 41% vs. 17% RR 2.4

3. Global Improvement in Pain– 47% vs. 12% RR 3.7

4. Double success: Depression and Pain– 26% vs. 8% RR 3.3

Life-style and pre-diabetic Neuropathy

• 12 month intervention with N=32

• Intraepidermal nerve fiber density (IENFD)– Proximal and Distal

• Michigan Diabetic Neuropathy score

• Results:– IENFD both increased – Change in proximal correlated with lower

neuropathic pain and sural sensory amplitude

Diabetic Care 2012

Knee OA and Acupuncture

0

2

4

6

8

10

12

14

Wk4 P

Wk4 F

Wk8 P

Wk8 F

Wk14 P

Wk14 F

Wk26 P

Wk26 F

Verum AcuSham Acu

Ann. Intern Med. 2004;141:901-910

GERAC Chronic LBP

Arch Intern Med 2007;167

Pain 146(2009)235-237

Hypnosis

Fibromyalgia: Behavioral Therapy

Cognitive BT• Alter negative feelings,

beliefs from dysfunctional thinking

• Identify harmful/incorrect thoughts disrupting progress

• Connect these with negative consequences

• Provide alternative coping and action strategies

• Internal nidus of control for helplessness

Cognitive BT• 6-24 months

• 50 % reduction in 40-55 % in study

• Responders: affective distress, low adaptive coping, less catastrophizing, low pain behaviors

• Cut MD visits, Hospital days, lowers cost

• Dose response

• 4 trials showed no responseCurrent Rheumatology Reports 2009, 11:443–450

Yoga Interventions: Pain and Disability

• Meta-analysis

• 12 randomized and 4 nonrandomized trials

• 6 trials for back pain

• 2 trials for headache/migraine

• Studies reported positive effect sizes– SMD for Pain -.74– SMD Overall Treatment -.79

Journal of Pain, 2012 Vol 13, No 1 : pp 1-9

Migraine Prevention

• Magnesium• B2/ riboflavin• Butterbur• Feverfew• CoE Q10• Acupuncture• Bio-feedback• Trigger Avoidances• Clin J Pain Volume 25, Number 5, June 2009

• Cochrane Database of Systematic Reviews. (1):CD007587, 2009.

• Acupuncture for migraine prophylaxis: update of Cochrane Database Syst Rev

“I’m investing less than 7 hours a month on headache prevention and getting next to no headaches”

“The world is full of suffering…

Its also full of overcoming it” Helen Keller

Pain Care Paradox

Standard Approach, Individual Treatment

1. Tincture of Time

2. Informed and Involved

3. Polymodal diagnosis & treatment

4. Community: More than Par-a-docs5. Improved outcomes 6. Fewer adverse events

Integrative Pain ProgramPain School

% change in measure 10/12 1/13 3/13• Fatigue - 28 -17 -24• Pain -13 -14 -14• Aerobic exercise >100 >100 >100 • Pain interfering -22 -46 -27 • Emotions interfering -22 -36 -28 • Non-Rx to control Sxs 31 13 24