Post on 12-Jun-2020
Interdisciplinary Chronic Pain Management
Sean Curran, BSc, MD, FRCP(C)Anesthesiologist, Credit Valley Hospital
Pain Management Unit, Hamilton Health Sciencescurransp@gmail.com
Disclosures
• none
Credentials
• Medical Doctor, University of Western Ontario
• Anesthesia, McMaster University
• Anesthesiology and Pain Management, Joseph Brant Hospital, Burlington
• Honourary Pain Fellow, FPM ANZCA, Royal North Shore Hospital, Sydney, Australia
• Pain Management, Hamilton Health Sciences
• Anesthesiology, Trillium Health Partners, Mississauga
Overview
• Cases
• History of interdisciplinary pain management
• Common elements
• Team members
• Admission criteria
• Program Comparisons
• Evidence
• Accessibility
Case 1
• Mr. C.K.
Case 3
• Mrs. J.W.
• 49 y.o. cardiac surgery for anomalous coronary artery
• IV-> compartment syndrome->fasciotomy
• Neuropathic arm pain
• Good function, mild depression
Case 2
• Mr. C. J.
• 54y.o. MVC--> back pain, headaches
• Medicalized (weekly back injections, physiotherapy, psychologist)
• Oxycodone
• Depression, suicidal thoughts, anxiety, agoraphobia, PTSD
• Functional impairment
Case 4
• Ms. A
• 37 y.o. from Somalia
• Widespread pain after MVC
• Depression, suicide attempt, auditory hallucinations
• Panic attacks, agoraphobia, PTSD, fearful, catastrophic thoughts
• Polypharmacy, benzodiazepine withdrawal, medication side effects
History
• Descartes 1664, Specificity Theory
History
• Chronic Pain
• Dualist paradigm
– Pathology: surgery, injection, medication
– Psychological
History
• Johnny “Bull” Walker
• 1941 NWA Light Heavyweight
Champion of the World
• Time magazine
– “founding father of pain
research and treatment”
History
• John Bonica, anesthesiologist
• 1942, MD, Marquette University
• 1953 Published “The Management of Pain”
• 1961 Multidisciplinary Pain Centre, University of Washington
• 1973 International Association for the Study of Pain (IASP)
• 2004 Professional Wrestling Hall of Fame
History: Bonica
• Integrated care
• Multiple health care professionals
• Restore function
• Alleviate pain if possible
• Improve pain management skills
History: Holistic
• Loeser 1980
Interdisciplinary Pain Management
• Comprehensive, co-ordinated team in same facility
• Biopsychosocial approach
• Common elements
– medication management
– graded physical exercise
– cognitive and behavioral techniques
Team Members
• Physician• Psychologist• Physiotherapist• Occupational Therapist• Social Work• Nursing• Pharmacist• Dietician• Administrative
Concepts
• Assessment
• Roles and Goals
• Education
• Pacing
• Relaxation
• Unhelpful thoughts
Education Topics
• Hurt vs. Harm• Healthy eating• Medication and sleep• Why your nervous system gets wound up• Acute vs. Chronic• Stress management• Self talk• Back and body care• Taking fitness home
CBT
• Instructions on relaxation, biofeedback, coping strategies, goal setting and changing maladaptive beliefs about pain
Pain'11; 152:S99-S106
CBT
Unpublished Doctoral Thesis, University of Leeds, UK; 2010
Admission Criteria
• Refractory pain
• Multidimensional impairments
• Reasonable goals
• Adequate grasp of English language
• Adequate cognitive function (ABI, dementia)
Exclusion Criteria
• Seeking cure or total analgesia
• Unstable medical conditions
• Substance abuse disorder
• Fall risk
Comparison
• ADAPT
– Sydney, Australia
– tough love
• CPMU
– Hamilton, Canada
– collaborative care
Evidence
• Flor et al
• meta-analysis of 65 studies, 3089 patients
• IPM vs no care, waiting list, medical management …
• Improved pain, activity, mood, health care utilization, medication intake
• Treatment effects maintained at 7 year follow up
Evidence
• Guzman et al
• Meta-analysis 10 RCTs CLBP
• Intensive (>100 hours) vs less intensive (<30)
• Strong evidence in support of intensive
Cost Effectiveness
Outcome Variable Interdisciplinary Conventional
Pain Reduction +/- +/-
Medication Reduction + -
Reduction of Emotional Distress
+ ?
Health Care Utilization + -
Iatrogenic Consequence + -
Activity/Return to Work + -
Closure of Disability Claims + ?
Critical Reviews in Physical and Rehabilitation Medicine 1998;10:181–208
Effect Size
Proc (Bayl Univ Med Cent). Jul 2000; 13(3): 240–243
Cost Comparison(millions USD)
Treatment Initial Subsequent 1 year post LifetimeDisability
Total
Interdisciplinary 142.6 25.3 197.1 1835.3 2200.4
Surgical 158.4 88.7 N/A N/A
Conventional 457.6 44.3 457.6 4226.8 5186.4
Okifuji et al, Handbook of Pain Syndromes. Mahwah, NJ: Lawrence Erlbaum Publishers,
1999:77–97
Evidence: Duration
• Patrick et al demonstrated lasting effects at 13 years
• Flor et al found results maintained 7 years
Accessibility
Pain Management Program
Canadian Journal of Anesthesia '07; 54(12):977–984
Chronic Pain Management Unit
• Chedoke Hospital, HHSC
• Intensive outpatient pain management program
• Psychologist, Registered Nurse, Occupational Therapists, Social Worker, Physiotherapist, Pharmacist, Dietician, Physicians