kevin cuccaro understanding pain - ohsu€¦ · the relationship of perceived pain to afferent...
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Understanding Pain(45 Years of Pain Science in < 45 Minutes)
Kevin Cuccaro, D.O.
1©Kevin Cuccaro, D.O.
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Faculty Disclosure:
The speaker, Dr. Kevin Cuccaro, has declared
they have no relevant financial disclosures.
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Learning Objectives
• Assess outcomes with common pain management
treatments
• Define modern pain science using a new conceptual
model.
• Describe how to assess and ‘deconstruct’ pain in
order to direct treatment.
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Today’s Goals
é Pain Awareness
Challenge Beliefs
Think Differently
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Kevin Cuccaro, D.O.
Before:
• Anesthesiology (Univ. of Chicago)
• ‘Pain Medicine’ (Univ. of Michigan)
• Assoc. Program Dir. (NMCSD)
• Board Certified ‘Pain Injection Specialist’
“Why aren’t people better?”
Now:
• Pain Specialist & Consultant
ü Healthcare Systems/PCPCH’s
ü OHA Clinical Innovations
Fellow
ü Oregon Pain Management
Commission
ü OHA HERC Chronic Pain Task
Force
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What We’ll Cover Today:
• Concept #1: What Is The Purpose of Pain & How Can People Hurt Even If
It Appears “Nothing’s Wrong”
• Concept #2: What Is The Most Common Misconception About Pain
Almost Everyone Makes (& Which Causes Treatments To Fail)
• Concept #3: How To Think Differently For Safe & Effective Pain
Treatment
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A Pain Problem?
Pain
• Common presenting
symptom
• Most common disability
• $600+ Billion annually
• 116 Million Americans*Available at: http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-
Transforming-Prevention-Care-Education-Research/Report-Brief.aspx. Accessed May 5,
2015
Back Pain
• 2nd Most Common Reason for
ALL Physician Visits
• Lifetime Prevalence of 60-90%
• Industrialized & Developing
World
• Disability Rates Very Different
Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of
low-back pain. Spine. 1987;12(7):632-44.
Allan DB, Waddell G. An historical perspective on low back pain and disability. Acta Orthop
Scand Suppl. 1989;234:1-23.
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Cost & BenefitWhat We Did…
• é MRI’s 300%
• é Procedures 130-700+%
• é Surgeries 300+%
• éOpioids 690+%
What We Got…
• é Disability Rates
• é Complication Rates
• é Healthcare Costs
No Improvement in Self
Reports
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Overall Results…
2000
US Pop. 282 Million
45 Million Chronic Pain
2010
US Pop. 309 Million
é9.6%
100 Million Chronic Pain
é122%
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Howé122%!?!
Despite More ‘Treatment’?
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What Is Pain?Concept #1: What Is The Purpose of Pain & How You Can
Hurt Even If It Appears “Nothing’s Wrong”
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Pain or No Pain?
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Pain or No Pain?
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Who Has Pain?
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How can someone…
Severe pain in their foot… but no spike?
Have a nail in their thumb…but little pain?
‘Spinal deformity’…but no pain?
‘Normal’ X-Rays…but tremendous pain?
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What Is Pain?
“Pain is an
unpleasant sensory & emotional
experience
associated with actual or potential
tissue damage or described in
terms of such damage.” IASP 1994
Unpleasant
Sensory AND Emotional
Bodily Experience
In Response To Perceived
Danger
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Key Concept #1The Purpose of Pain Is Protection Not Punishment
“Hurt ≠ Harm”
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1. Protection Not Punishment(“Hurt” ≠ “Harm”)
‘Harm WITHOUT Hurt’
• Distraction
• Life or Death Events
• General Anesthesia
• Belief of Harmlessness
‘Hurt WITHOUT Harm’
• High (But Not Too High) Threat
• Expectation of Harm or
‘Vulnerable’ Expectation
• Belief of Harm
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Pain ≠ Damage!No Pain Pain!
Key Concept #1: The Purpose of Pain Is ProtectionHurt ≠ Harm
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Key Concept #2
Pain Does NOT “Come From…” The Body
Pain Is “Constructed” In The Brain
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IF Pain “Came From…”
…Then cutting, poking,
adjusting, drugging, ‘Pain Pus
Pathways’ would consistently
& predictably work with
sustained results…
But is this true?
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Maybe Our Model Needs An Update…?
Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-6.
16th Century 21st Century
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How We Construct Pain
Unpleasant
Sensory AND Emotional
Bodily Experience
In Response To
Perceived Danger
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How We Construct Pain
Unpleasant
Sensory AND Emotional
Bodily Experience
In Response To
Perceived Danger
Sensation (Feeling)
‘Where is it?’ & ‘What is it like?’
+
Emotion (Meaning)
‘What does this mean?’
+
Cognition (Thinking)
‘Does it matter right now?
& What should I do?’
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Confusing? Not ReallyFirefighters Understand This Pain
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Fuel, Heat, & Oxygen of Pain
Cognition/Attention (“Heat”)
– Threat Appraisal
– Accidental vs. Intentional
– Uncertainty & Anxiety
Sensation/Transmission (“Fuel”)
– A-Beta vs. A-Delta vs. C-fibers
– Interoceptive, Proprioceptive…
– ‘Top-Down’ Influences
Emotion/Meaning
(“Oxygen”)
– Fear & Loss Meaning
• Ex. Abd Pain
– Anger & Injustice
– Loss & Depression
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Important: What Is This?
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Structure OR Sensation Alone ≠ Pain
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Key Concept #2: Pain is Constructed.It Does Not “Come From…”
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Key Concept #3:
If You Know What You’re Treating…
You Know How To Treat It
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Firefighters Understand Fire
Then ‘Deconstruct’ It To
Target Treatment
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The Same Applies To Pain
‘Pain Fire’ Examples
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Spike In Boot
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Sensation/Transmission (“Fuel”)
– ‘Tissue Issues’ or No?
Cognition/Attention (“Heat”)
– Threat, Uncertainty, Anxiety?
Emotion/Meaning (“Oxygen”)
– Fear, Loss/Harm Meaning?
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Nail In Thumb
Sensation/Transmission (“Fuel”)
– ‘Tissue Issues’ or No?
Cognition/Attention (“Heat”)
– Threat, Uncertainty, Anxiety?
Emotion/Meaning (“Oxygen”)
– Fear, Loss/Harm Meaning?
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Nail In Thumb
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‘Normal Spine’
Sensation/Transmission (“Fuel”)
– ‘Tissue Issues’ or No?
Cognition/Attention (“Heat”)
– Threat, Uncertainty, Anxiety?
Emotion/Meaning (“Oxygen”)
– Fear, Loss/Harm Meaning?
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‘Normal Spine’
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Scoliosis
Sensation/Transmission (“Fuel”)
– ‘Tissue Issues’ or No?
Cognition/Attention (“Heat”)
– Threat, Uncertainty, Anxiety?
Emotion/Meaning (“Oxygen”)
– Fear, Loss/Harm Meaning?
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Scoliosis
No Pain
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Why This MattersWhat We Assume About Pain What ALL Pain Actually Is
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“Your Pain Is Coming From…”
How We ‘Treat’ Pain…
• Increased MRI’s 300%
• Increased Procedures 130-700+%
• Increased Surgeries 300+%
• Increased Opioids 690+
• Structure-Focused Therapy
• Body-Focused Messaging
Focused Here
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Different ‘Fires’ May Have Different Primary Treatment…
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…But Multiple Places To Intervene…
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Most Important…Often Not Appreciated
• Genetic/Epigenetic
• Developmental
– Childhood Illness, Abuse, Neglect
• Adult Victimization/PTSD
• High Stress
– Early Life
– Chronic Stress
– Acute Stressors
• Anxiety
• Depression
• Pain Beliefs &
Expectations
• Maladaptive Coping– Pain Intensity
– Nonorganic Signs
– High Baseline Impairment
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But Where Improvement Seen…
Changes In:
• Pain Beliefs
• Coping Strategies
– Passive èActive
• Pain Self-Efficacy
• Psychological Distress
(Even With ‘Physical’ Modalities)
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The Challenges of Pain
• Pain Constructed from 3
Elements
– But Focus Is on 1.
• Medical Tx Limited
– Rx. Are ‘Fast’
– Surgery & Injections are
Profitable
• Misinformation, Fear &
False Beliefs
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The Goals
• Understand Pain
• Question Beliefs
• Think Differently
(Like A Firefighter)
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The Key Concepts…
• Key Concept #1: The Purpose of Pain Is Protection,
éDanger (not Damage) éPain
• Key Concept #2: Pain Is Constructed, It Does Not
“Come From…”
Requires Three Dimensions To Construct (Not One)
• Key Concept #3: Understand Pain & How It Is
Constructed…Then ‘Target’ Your ‘Treatments’ (Like
A Firefighter).
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ReferencesInstitute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. Available from: https://www.ncbi.nlm.nih.gov/books/NBK91497/doi: 10.17226/13172
Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy. Expert Rev Neurother. 2013;13(11):1201-20.
Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off?. J Am Board Fam Med. 2009;22(1):62-8.
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