Biopsychosocial management of Chronic Pain

Symon Mccallum

I am out of date already!

Psychosocialbiomedical approach…...i think

Rebranding…....

• Chronic pain is dead!

• Long live Persistent Pain!

What can we do about chronic pain?

• Pharmacology

• Non pharmacological

• Interventional

Prevalence of Pain (1)

• 1 in 5 Australians suffers chronic pain

• 80% of these people are missing treatment that could

improve their quality of life

Scope of the Problem – Chronic Pain

(1) Blyth FM, March LM, Brnabic AJM, Jorm LR, Williamson M and Cousins MJ, 2001. Chronic pain in Australia: a prevalence study. Pain 89:127-134.

Cost (1)

• Chronic Pain costs the Australian economy approximately $34 Billion

per annum

• Much of this cost is carried by the patient

• Applying EBM approaches to management could halve this cost

(i.e. a saving of $17 Billion per annum)

(1) Access Economics – Based on Australian Institute of Health and Welfare (2005)

Scope of the Problem – Chronic Pain

Australian return to any work rates

Management - Evidence

Management - Evidence

• Watson (EJP 2004)

– 60% RTW following MDT pain program

• Poulin (ESJ 2010)

– 55% RTW sustained at 3.5 y (vs 9% pre-program)

• Guzman (BMJ 2001)

– MDT programs more effective than any other intervention

12

characteristics of the injured worker

components of particular medical and occupational rehabilitation interventions

physical and psychological job characteristics

workplace factors

the workers compensation scheme, labour market conditions, and

the prevailing legal framework (2006: 4).

As Figure 1 demonstrates, the return to work processes has multiple dimensions and operates across

workplace, health care, legislative and insurance, and personal systems. It is a complex process involving

multiple stakeholders – the injured worker, the employer, health and rehabilitation providers and

insurance providers.

Figure 1: The multi-dimensional aspects of RTW

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Arena of Work Disability

Loisel et al, Journal of

Occ. Rehab, 2005

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In South Australia the response to injured workers through the WorkCover scheme involves a range of

stakeholders. The worker, the insuring agent, the employer, treating medical experts, rehabilitation

providers, work colleagues, friends and family have all been identified as critical elements in the return to

work process (Roberts-Yates, 2006: 898). The interactive effect of the different stakeholders involved

means that successful RTW will be influenced by more than a single factor. For example, South Australian

research has identified these four variables as having the most significant, but combined, impact –

Reasons For Not Returning To Work

Major Hurdles for RTW

• 84% state reason as being pain

• Medication dependence

• Fear of re-injury

• Perceived disability

• Anxiety and depression

ASCEND Pain Management

What is Ascend?

• Multidisciplinary Pain Management Program

• Out-patient day program

• Education

• Functional restoration

• Mindfulness training

• Dispelling unhelpful beliefs

• Medication reduction/cessation

Who is ASCEND?

• Physiotherapy

• Nurse specialist

• Clinical Psychology

• Occupational Therapy

• Myotherapy/Personal Training

• Pain Medicine Physician

• Neuro and Spinal Surgeon

Who is ASCEND for?

• Injured workers

• TAC patients

• Pain for greater than 6 weeks

• Difficulty returning to work

• Pain related distress

• Medication reliance

• Fear of re-injury

• Red flags excluded

Case scenario

• By end of 6 week program:

– Improved function

– Improved mood

– Medications ceased

– Improved sleep

– Improved work capacity

– Improved QoL

– Keen to return to usual work hours/duties

Doctor and patient resources

• Rewire Your pain

• Understand pain

• Brainman and opioids

Pain for more than 6 monthsWhere are we going?

Active treatments only

Physiotherapystretches, exercises, moving, sweating!HydrotherapyYogaPilatesDecent educationWalking

? Exercise physiologist

Pain for more than 6 monthsWhere are we going?

• Psychology– All pain is in the brain

– You are not making it up

– Relationship of pain, anxiety, depression and catastrophising thoughts.

– PTSD

– Acceptance

– Relaxation

– Desensitization

– Decision making

STEPS

STEPS• Evidence

– It is as effective as physiotherapy-even core strengthening exercises

– Cheap

– Social

– Can be done several times a day

– An important part of life

– Can be done inside

– Very unlikely to cause an injury

– Cheap

– If you walk more, you have less morbidity and mortality

STEPS

• Evidence

– Does not result in sustained results with rewards.

– People don’t use them for long

– Chronic pain patient’s activity levels are the same as control groups

My patients

• Do 1,500 to 3,000 a day.

• My approach

– Wear it for a week

– Increase average by 100 to 200 a week.

– Every week.

– For months and months.

– Record and encourage.

Boom - bust

• My approach– Focus on bad days

– Boom – bust behavior results in a gradual decrease in activity over time.

Fear avoidant

Future

• Occupational physician

• Do not rely on return to work coordinators or occupational therapists.

• Motivational interviewing –realistic goals.

Dope and Hill Billy Heroin

Cannabis and chronic painonly

Cannabis and chronic pain

For

• Cannabis is a mixture of cannabinoids and other compounds – better than cannabinoid medications.

• Low chance of overdose.

• Not as harmful as opioids.

• Is an ancient medicine.

• Is cheap.

Against

• Herbal cannabis is complex, variable and often unknown.

• Used recreationally and associated with harm.

• Not needed.

• Arguments are for general use.

• Smoking is harmful

What are we talking about?

Cannabis – 3 major speciesCannabis sativa, Cannabis indicate and

Cannabis ruderalis537 constituents, 107 unique to cannabisDelta-9-tetrahydrocannabinol (THC) is the most studied.

Psychotropic effects.Cannabidiol (CBD)

Shown to modulate inflammation, pain, spasticity, epilepsy and nausea. No euphoria.

The Times They are a Changin'

THC concentration

1980's 3%2009 9%

Highest THC conc 37%Hashish 66%Hash oil 81%

What do they do?

Humans produce endogenous cannabinoids = endocannabinoids

Herbal cannabinoids – photocannabinoids

Bind to cannabinoid type 1 and type 2 receptors.

Metabolised by two major enzymes.

What do they do?Endocannabinoids involved in:

Temperature controlPain modulation

Appetite inductionNausea modulationCellular migration

Control of inflammation

CB1 mainly in the brain

CB2 in leukocyte, peripheral cells, astrocytes and microglia.

Cannabinoid Drugs

• Dronabinol, synthetic THC.– Chemotherapy nausea and AIDS induced wasting

syndrome.– Shown efficacy to treat pain.– Use limited by side effects.

• Nabiximol (Sativex), THC and CBD– Neuropathic pain and spasticity due to MS– Shown to help diabetic neuropathy. Mixed results for

cancer pain.– Similar side effect profile limits use.

Neuropathic pain

• 5 decent randomised controlled clinical trials for smoked cannabis.

– Decrease in mean VAS are modest and similar to opioids, antidepressants or convulsants.

– Studies showed• NNT for a 52% decrease in pain was 2 • NNT for 30% decrease was 3.5

• Similar studies for FBM and Rheumatoid arthritis.

Side effects and Risks

• Dizzy, dry mouth and drowsy.

• Psychobehavioural– Cognitive, psychomotor, perceptual alterations and

euphoria.– Can worsen psychotic illness.– Can precipitate psychosis in vulnerable individuals.– Early or heavy use may be associated with increased

risk of schizophrenia in adulthood.– Positively associated with anxiety disorders. Causality

unclear.

Regular heavy use:

• Persistent intellectual, cognitive and motivational changes.

Lifetime risk of dependence for users• Cannabis 9% (?17% in adolescents)

• Nicotine 22.7%

• Alcohol 22.7%

"It will all be fine with risk assessment"

• Universal precautions.

• Cannabis agreements.

• Urine drug screens.

Unknowns

• Use in adolescents and neuordevelopmenaleffects.

• At what age is cannabis most harmful?• Inconsistent findings with neuroimaging.

– ?Altered resting state

• How much cannabis is too much?• Sex differences.• Genetic polymorphism and neuropsychological

impairment.

Analgesics

• Why?

– Decrease pain

– Increase function

– Minimal side effects

Prescribing Opioids for chronic pain

• 1) Diagnosis.

• 2) Are opioids right for this patients pain?

• 3) Is this patient right for opioids?

• 4) Treatment plan.

• 5) Assessment.

1) Diagnosis

1) Diagnosis

2) Are opioids right for this patients pain?

3) Is this patient right for opioids?

3) Is this patient right for opioids?

3) Is this patient right for opioids?

Opioid Risk Tool

0-3

LOW

RISK

8+

HIGH

RISK

4-7 MODERATE

RISK

1. Kahan M et al. Can Fam Physician 2006;52(9):1081–7. 2. Webster LR, Webster RM. Pain Med 2005;6(6):432–42.

Factor Males Females

Family history of substance abuse

- Alcohol q 3 points q 1 point

- Illicit drugs q 3 points q 2 points

- Prescription drugs q 4 points q 4 points

Personal history of substance abuse

- Alcohol q 3 points q 3 points

- Illicit drugs q 4 points q 4 points

- Prescription drugs q 5 points q 5 points

Aged between 16 and 45 q 1 point q 1 point

History of preadolescent sexual abuse q 0 points q 3 points

Psychiatric disease

- Attention deficit disorder, obsessive-compulsive disorder, bipolar disorder, schizophrenia

q 2 points q 2 points

Depression q 1 point q 1 point

4) Treatment plan

• 1) Informed consent.

• 2) Goals.

• 3) Stopping opioids.

• 4) Ongoing trial.

5) Assessment.

Analgesia

Activity

Adverse Effects

Aberrant behavior

Affect

Accurate prescribing and documentation

Does it hurt?

• Report of pain is influenced by

– Nociception

– Dysfunction

– Mood status

– Cultural conditioning

– Secondary gain

– Coping repertoire

– Beliefs

What to prescribe?

Maximum oral morphine equivalent recommended dose is 120mg per day

What do I do?

• Comorbidities?

• Benzodiazepines, alcohol, drugs?

• Start low

• Significant analgesic and functional improvements?

• If not, stop.

What do I do?

• Prn Palexia IR, or endone is not evil

Side Effects of opioids

• Hormones

– Testosterone. ? supplement

– Cortisol

– FSH and LH

• Lethargic, fatigue, sweating, sexual dysfunction, anxiety and depression.

• Osteoporosis.

Side Effects of opioids

• OSA

Palliating Chronic Pain?

American Academy of Neurology

• The risk of death, overdose, addiction or serious side effects with prescription opioids outweigh the benefits in chronic, non-cancer conditions such as headache, fibromyalgia and chronic lower back pain.

American Academy of Neurology

• “More deaths from prescription opioids in the most vulnerable young to middle-aged groups than from firearms and car accidents.”

American Academy of Neurology

• “50% of patients taking opioids for at least 3 months are still on opioids 5 years later.”

Efficacy and Potency

• Analgesic efficacy DOES NOT equal increased Quality of Life.

Why do opioids Fail?

Tolerance

– Receptor internalisation

– NDMA receptor changes

– Spinal dynorphins

– Anti opioids effects – vasopressin, oxytocin, nociceptin and CCK

Opioid induced hyperalgesia

Withdrawal

New Kid on the Block• Palexia SR and IR

– Pharmacologically like tramadol, but NA instead of serotonin.

– Effective for nociceptive and neuropathic pain.

– Little tolerance.

– Well tolerated.

– Low likeability.