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Dr. Kashyap Patel Chief Medical Officer, Agape Healthcare

President, SCOS 2014-15Board member, community oncology alliance

Chief of Staff, Springs Memorial HospitalCAC Member, Palmetto-GBA, Medicaid,SC

I have no conflict of interest to declare I will not be discussing any off label use of any

products I will not be mentioning any brand name or

commercial drug

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Recognize the prevalence, magnitude, challenges and opportunities for multidimensional approach to chronic pain in the US

Describe the science and evidence behind different components of integrative medicine based approach to pain management

Utilize innovative ideas to incorporate integrative approach to pain management

POPULATION HEALTH INDIVIDUAL PATIENT AND CARE GIVER The annual cost of chronic

pain in the United States is estimated to be $100 billion (healthcare expenses, lost income, and lost productivity)

Chronic pain is common, exists as the number one cause of disability in the United States, and creates a large burden on the healthcare system.

Back pain is the leading cause of disability in Americans under 45 years old.

More than 26 million Americans between the ages of 20-64 experience frequent back pain.

50 million Americans live with chronic pain An additional 25 million live with acute pain Mismanagement of pain has far reaching societal

consequences In fighting illicit misuse, must not hinder patients’

access to beneficial medical treatments Non-medical use of prescription drugs = 2nd most

commonly abused drug category Prescription drug abuse is 3x more prevalent than

illicit use of cocaine, crack, and hallucinogens This pattern presents both challenges and

opportunities in creating integrative approach to pain management

76 78 8086 91

96 100109

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139 144151

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1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

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IMS Vector One. From “Prescription Drug Abuse: It’s Not what the doctor ordered.” Nora Volkow National Prescription Drug Abuse Summit, April 2012. Available at http://www.slideshare.net/OPUNITE/nora-volkow-final-edits.

http://www.slideshare.net/OPUNITE/nora-volkow-final-edits

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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Alcohol only Alcohol w/secondary drugHeroin Other opiatesCocaine Marijuana/hashishStimulants Other drugs

SAMHSA Treatment Episode Data Set, 2000-2010.

NCHS Data Brief, December, 2011. Updated with 2009 and 2010 mortality data.

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1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Dea

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Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose)

Specified drug(s) other than opioid analgesic

Any opioid analgesic

Only non-specified drug(s)

CDC, National Center for Health Statistics, National Vital Statistics System.

Chart1

199919991999

200020002000

200120012001

200220022002

200320032003

200420042004

200520052005

200620062006

200720072007

200820082008

200920092009

201020102010

Opioid analgesic involved drug poisoning

Only non-specified drug(s) involved drug poisoning

Specified drug(s) other than opioid analgesic involved in drug poisoning

Number of deaths

4030

3566

9253

4400

3942

9073

5528

4420

9446

7456

5288

10774

8517

5910

11358

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Sheet1

YearOpioid analgesic involved drug poisoningOnly non-specified drug(s) involved drug poisoningSpecified drug(s) other than opioid analgesic involved in drug poisoning

19994,0303,5669,253

20004,4003,9429,073

20015,5284,4209,446

20027,4565,28810,774

20038,5175,91011,358

20049,8576,25311,314

200510,9286,82212,063

200613,7237,96412,738

200714,4088,85612,746

200814,8009,24212,408

200915,5979,19612,211

201016,6519,42912,249

CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Opioids Heroin Cocaine Benzodiazepines

$72.5 billion in health care costs1

Opioid abusers generate, on average, annual direct health care costs 8.7 times higher than nonabusers2

1. Coalition Against Insurance Fraud. Prescription for peril: how insurance fraud finances theft and abuse of addictive prescription drugs. Washington, DC: Coalition Against Insurance Fraud; 2007.2. White AG, Birnbaum, HG, Mareva MN, et al. Direct costs of opioid abuse in an insured population in the United States. J Manag Care Pharm2005;11(6):469-479.

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000

CDC. MMWR 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w. Updated with 2009 mortality and 2010 treatment admission data.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w

Pain often co-exists with mood, sleep, and functional disorders that require additional attention for optimal management: Sleep Disturbance. 20% of American adults (42 million people)

report that pain disrupts their sleep a few nights a week or more

Depression and Anxiety. Example in facial pain and its relation to anxiety and depression: A cross-sectional study on 649 patients. The analysis showed that, regardless of the diagnostic group, anxiety and depression independently increase the likelihood of having … higher muscle tenderness...

Chronic back pain is accompanied by brain atrophy (1.3 cm3 loss of gray matter/year of pain;

*Apkarian J et al. Neurosci. 2004 24 (46): 10410.

Chronic back pain is accompanied by brain atrophy (1.3 cm3 loss of gray matter/year of pain; see figure above)Cortical Plasticity: Adult brain (is) capable of substantial plastic change in primarysomatosensory cortex ... formerly thought to be modifiable only during early experience...Cortical plasticity related to chronic pain can be modified by behavioral interventionsthat provide feedback to the brain areas that were altered by somatosensory painmemories.fMRI biofeedback for control of brain activity in pain patients: “…individuals can gain voluntary control over specific brain region given appropriate training, these effects were powerful enough to impact severe, chronic clinical pain.

1. NIH Consensus Statement: a. Strong evidence for the use of relaxation techniques in

reducing chronic pain in a variety of medical conditions, b. Strong evidence for the use of hypnosis in alleviating

pain associated with cancer2. Mind-body medicine: state of the science, implications for practice. “There is considerable evidence of efficacy for several

mind–body therapies in the treatment of headaches, insomnia, chronic low back pain, symptoms of cancer, and improving post surgical outcomes.”

3. Examples: Behavioral van Tulder et al. Therapy in Low `Back Pain: Behavioral treatment for

chronic low back pain: a systematic review Cochrane Back Review Group. Spine. 2000;25:2688-2699

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Relieve acute and chronic pain Employ appropriate pharmacological and

nonpharmacological techniques Minimize side effects

PATIENTS FIND MORE SATISFACTION FROM CAM

INTERVENTION PERCEIVED TO BE MOST EFFECTIVE FOR LBP

Massage 65% Chiropractic 61% Relaxation techniques 43% Conventional providers 27%Patients rated CAM as "very helpful" for back / neck pain

Alternative medicine 62.8%Therapeutic exercise 56.9%Bed rest 51.9%Physical therapy 46.8% the least effective were

physicians' office visits. A gap was found between clinical guidelines and physicians referrals for other therapeutic interventions.

Non-opioid Analgesics Used for mild to moderate nociceptive pain Anti-inflammatory drugs (NSAIDs) Carry risk of gastrointestinal bleeding and impaired

renal function Avoid persistent use in older adult population

Acetaminophen (Tylenol) Use safe with older adults having normal kidney and liver

function and no history of alcohol abuse Dosages not to exceed 4,000 mg/day

Non-opioid Analgesics Anti-inflammatory drugs (NSAIDs) Cyclooxygenase-2 (COX-2) Tramadol Used for moderate pain May cause dizziness, nausea, and headache

Opioid analgesics Used for moderate to severe pain management May be used for long periods of time without risk of

organ damage Available in a variety of routes Titrate slowly Mild sedation and cognitive impairment are

anticipated in initial therapy

Opioid analgesics Potential medications Morphine Meperidine Methadone Oxycodine Fentenyl Transdermal

Opioid analgesics Potential adverse effects Constipation Sedation Respiratory depression Nausea and vomiting Myoclonus Pruritis

Adjuvant drugs for chronic pain Examples Antidepressants and anticonvulsants Topical analgesics Muscle relaxants Antianxiety medications

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PATIENTS FIND MORE SATISFACTION FROM CAM

INTERVENTION PERCEIVED TO BE MOST EFFECTIVE FOR LBP

Massage 65% Chiropractic 61% Relaxation techniques 43% Conventional providers 27%Patients rated CAM as "very helpful" for back / neck pain

Alternative medicine 62.8%Therapeutic exercise 56.9%Bed rest 51.9%Physical therapy 46.8% the least effective were

physicians' office visits. A gap was found between clinical guidelines and physicians referrals for other therapeutic interventions.

CAM-complementary and alternative medicine Specific therapies/modalities Not typically taught, used or reimbursed in USA

hospitals A group of diverse practices not presently

considered part of conventional medicine 5 domains defined by NIH-NCCAM Mind/Body Biological Manipulative/Body- based Alternative Systems Energetic

Integrative Medicine-A system of care that emphasizes wellness and healing Principles Mind/body/spirit Patient –provider as collaborative partners Natural, less invasive approaches when possible Facilitating the body’s natural healing capacities Need for provider self-care Conventional and CAM in balance Customized to patient need and preference Balance of evidence and safety considerations

Psychological approaches Counseling Biofeedback Imagery Hypnosis Relaxation

Mind-body medicine focuses on the interaction among the mind, thoughts, brain and body. It explores the ways in which

emotional, mental and spiritual attitudes can directly alter the

status of health.

Mind-Body Interventions and healthy outcomes The treatment of disease Decrease pain Helps physicians deal with compassion fatigue Improve mood, QOL, and coping Improve disease or treatment related symptoms

Mind-Body connection Immunity Positive effects of emotions on immunity

Meditation and Imaging Use of fMRI to investigate the effects of meditation on the

activation of regions of the brain Stress and Wound Healing

Positive and negative effects of mood or stress on the rate of wound healing

Surgical Preparation Reduce discomfort and adverse effects

Genomic changes introduced by relaxation response

Dusek JA, Otu HH, Wohlhueter AL, Bhasin M, et al. (2008) Genomic Counter-Stress Changes Induced by the Relaxation Response. PLoS ONE 3(7): e2576. doi:10.1371/journal.pone.0002576http://www.plosone.org/article/info:doi/10.1371/journal.pone.0002576

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0002576

PARIETAL LOBE FRONTAL LOBE

Physical therapy Ultrasound Exercise Hot and cold packs

Neurostimulation

Behavioral Therapy Herbal therapy Biofeedback Physical Therapy Osteopathic

Manipulation Craniosacral Therapy

Acupuncture Massage Yoga Reiki

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Pharmacologic therapy

Mind Body and integrative approach

Wholisticapproach

Combined integrative approach

Non narcotic

Naorctoic for a small selected

sub group

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Integrative Approach to pain managementConflict of interest declarationObjectives: �At the end of the presentation participants will be able to:Burden of Chronic pain: Population and IndividualWhy Current approach with aggressive narcotic use is sub-optimal pain managementOpioid Prescriptions Dispensed by Retail Pharmacies—United States, 1991–2011Primary Substance of Abuse at Treatment Admission—United States, 2000–2010Motor Vehicle Traffic, Poisoning, and Drug Poisoning (Overdose) Death Rates�United States, 1980–2010Number of Drug Overdose Deaths Involving �Opioid Pain Relievers and Other Drugs�United States, 1999–2010Drug Overdose Deaths by Major Drug Type,�United States, 1999–2010�Economic CostsRates of Opioid Overdose Deaths, Sales, and Treatment Admissions, United States, 1999–2010Why Integrative approach to pain management is beneficialNeurocognitive alteration and potential therapeutic approachesCognitive behavioral therapy and Mind Body interventions in chronic painSlide Number 16Pain Management GoalsChronic pain requires an integrative / holistic approachPharmacological ManagementPharmacological ManagementPharmacological ManagementPharmacological ManagementPharmacological ManagementPharmacological ManagementSlide Number 25Chronic pain requires an integrative / holistic approachIntegrative Medicine Vs. CAM 1Integrative Medicine Vs. CAM 2Nonpharmacological Methods to Manage Pain – Based on Mind body interventions IntroductionResearch in Mind Body MedicineMind body intervention and changes in Neuro-endocrine-immune axisGenomic changes during meditation: Genes can be modifiedSlide Number 34Spect Images at baseline and meditationLatest evidence of Mind Body Approach in Pain ManagementOther Nonpharmacological Methods to Manage Chronic PainIntegrative Toolkits for Chronic Pain ManagementSlide Number 39APPROACH TO CHRONIC PAINEvidence based approach to chronic painTHOUGHTS?�QUESTIONS?