toward integrative mind-body interventions for the treatment of chronic pain in veterans pain and...
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Toward Integrative Mind-Body Interventions for the
Treatment of Chronic Pain in Veterans
PAIN AND THE BRAIN
Karen H. Seal, MD, MPHDirector, Integrated Pain TeamDirector, Integrated Care Clinic for Iraq and Afghanistan VeteransSan Francisco VA Medical CenterUniversity of California, San Francisco
OUTLINEChronic Pain: • epidemiology, neuroscience, psychology
Biomedical Model • focus on fixing the physical source of pain
Biopsychosocial Model • multi-modal pain management
Integrative Model: • emphasizes mind-body pain self-management
SCOPE OF THE PROBLEM
42% with pain lasting over one year
33% report pain as disabling Second most common
reason for outpatient visits CHD Diabetes Chronic Pain
0
20
40
60
80
100
120
19 21
100
Prevalence in Millions
Healthcare expenses Lost income Lost productivity
$600 Billion Annual Costs
American Academy of Pain Medicine www.painmed.org Institute of Medicine. 2011 Relieving Pain in America. Washington D.C.
100 Million in U.S. with Persistent Pain
Iraq/AfghanistanVeterans – carry heavy combat equipment/body armor and weaponry > 100 lbs Chronic pain more prevalent in
female OEF/OIF/OND vets3,4
>50% with PTSD have received chronic pain diagnoses5
CHRONIC PAIN IN VETERANSMost prevalent problem among US Veterans
1. Beckham, JC, et al. J Psychosom Res. 1997 Oct;43(4):379-89.2. Shipherd, JC, et al. J Rehabil Res Dev. 2007;44(2):153-66.3. Frayne, SM, et al. J Gen Intern Med. 2011 Jan;26(1):33-9.4. Haskell, SG, et al. Pain Med. 2009 Oct;10(7):1167-73.5. Seal KH. “PTSD in Combat Veterans: Exploring the Association with Chronic Pain and Prescription Opioid Use” American Psychological
Association, Annual Meeting, Honolulu, HI, July 31- Aug 4, 2013.
Series150%
75%FemaleMale
Vietnam66%- 80% of Vietnam veterans with PTSD reported chronic pain1,2
DEVELOPMENT OF CHRONIC PAIN
Anxiety/hyperarousal – pain perceptionPTSD re-experiencing - evokes painDysregulated ANS/Endog. Opioid system
CHRONIC PAIN AND PTSD: MUTUAL MAINTENANCE
Adapted from Sharp TJ, Harvey AG. Clin Psychol Rev. 2001 Aug;21(6):857-77 .
Pain
Anxiety
PTSD
Disability
Biomedical Management of Chronic Pain
BIOMEDICAL MODEL OF PAIN CARE
• Diagnostics to ID singular cause of pain
• Interventions target peripheral tissues
• Mind and body are separate
• Passive interventions
• Primarily mono-therapies
• “Kill the Pain”
• We can fix it!
• Complete pain relief is possible!
Butler, Neuro Orthopedic Institute WCPT 2011
PRESCRIPTION OPIOIDS & ADVERSE OUTCOMES IN IRAQ AND AFGHANISTAN VETS
Receiving prescription opioids was associated with an increased risk of adverse clinical outcomes, particularly in veterans with PTSD
Wounds or injuries
Opioid-related accidents and overdoses
Self-inflicted injuries/Suicide
Violence-related injuries
Seal, KH, et al. JAMA. 20127.
BUT…..Are Opioids Really Effective Against Pain?
Noble, M. The Cochrane Collaboration. 2010
OPIOIDS AND CHRONIC PAIN-RISKS V. BENEFITS
• Uncertain Benefits:
• ? Pain relief
• ? Improved physical functioning, QOL
• Potential known harms:
• Fatal overdose
• Tolerance/physical dependence
• Addiction/abuse/diversion
• Respiratory depression--avoid in COPD
• Cognitive impairment--avoid in dementia
• Endocrine disruption- ED, muscle wasting, fatigue, OP
• Sleep disturbances; worsening sleep apnea
• Hyperalgesia on higher dose opioids
CULTURAL TRANSFORMATION IN THE WAY PAIN IS VIEWED, ASSESSED, AND TREATED
Biomedical To Biopsychosocial Model
BIOPSYCHOSOCIAL MODEL OF PAIN
PAIN Not just a symptom
but your patient’s lived experience
Functional Disability
Psycho-social
Pain
GOALS OF CHRONIC PAIN MANAGEMENT
• Restore functioning• Improve quality of life• Reduce pain
“A car with four flat tires”
Medications only fill one tire
SELFMGT
MULTIMODAL CHRONIC PAIN CARE
Behavioral
CBTMood/trauma therapiesSubstance abuse TxSleep HygieneMeditation/Relaxation
ProceduralNerve blocks/ablationSteroid injectionsTrigger point injectionsStimulators
Physical
Gentle exerciseManual therapies
AcupunctureYoga, Chigong
Others
MedicationNSAIDSAnticonvulsantsAntidepressants
Topical agentsOthers
• Interdisciplinary care: MD, NP, pain psychologist & pain pharmacist
• Biopsychosocial Model
• Optimize non-opioid pain care; decrease opioid risk
• Improve function and QOL
• Dissemination to rural VA clinics
• Quality Improvement (QI) research
Gatchel et al., 2014; Wiedemer et al., 2007; Dorflinger et al., 2014
SFVAHCS Integrated Pain Team
GROWING EVIDENCE BASE
Integrative Chronic Pain Care
INTEGRATIVE MODALITIES FOR PAIN
• Safer in patients with comorbidities and polypharmacy
• 30-50% of veterans use CAM/Integrative modalities; only 1/3 disclose to their PCPs Smeeding et al., 2005
• Integrative modalities for pain are NOT available at SFVAMC despite patient preference for CAM
INTEGRATIVE (CAM) THERAPIES—PAIN
25
National Center for Complimentary and Integrative Health http://nccam.nih.gov/health/pain/chronic.htm?nav=gsa
“Motion is the Lotion”
The good physician treats the disease; the great physician treats the patient who has
the disease. -Sir William Osler, circa 1900
© 2014 JPEP PAIN MANAGEMENT CURRICULUM
INTEGRATIVE PAIN MANAGEMENT STARTS WITH VETERANS’ CORE VALUES AND FUNCTIONAL GOALS
40 y.o. vet with chronic pain and PTSD on high-dose opioids
• Focus on values: “What are some of the things you value most in life?”
“Spending time with family; Supporting my family”
• Focus on functional goals: “Given what you value, what are some things you would like to do if you were able to get your pain under better control?”
“Camping and hiking in nature with family; finishing school and getting a good job”
SHARED DECISION-MAKING
Integrative Pain Care Plan
Taper opioids (morphine) with pain pharmacist so not overly sedated
Add topical creams and anti-inflammatories for pain (instead of opioids)
Go to gentle yoga class to get more mobility and strength and learn stress reduction
Start PTSD group at the San Francisco VA
Take a hike in nature on week-ends with family
SPECIAL THANKS!!
Integrated Pain Team and QI Staff: Sarah Palyo, PhD (Clinical Director); Caitlin Garvey NP; Christina Tat, Pharm D; Erin Watson, PhD; Wilson Fong, NP; Payal Marpara, PhD; David Villasenor, MD; Emily Sachs, PhD; Joe Grasso, PhD, Natalie Purcell, PhD, Kara Zamora, PhD, Christopher Koenig, PhD, Tessa Rife, Pharm D.
Leadership Support: Rina Shah, MD; Diana Nicoll, MD, PhD; Bonnie Graham, MBA; Ken McQuaid, MD; Mike Shlipak, MD, MPH; Carl Grunfeld, MD.
QUESTIONS? WANT TO GET INVOLVED?